Full Name

Date of Birth

Full Address

Telephone

Mobile

Email

Doctors Name

Surgery Name

Surgery Address

Please confirm: Please confirm: I would like Chel Pharmacy to keep my repeat slip to order my medication on contact from myself or representative I would like Chel Pharmacy to collect my prescription from my surgery, either in person or by means of electronic transfer. By ticking these boxes, I confirm that I will inform Chel Pharmacy if I wish to make changes to these arrangements.

Are you the: Are you the: Patient Authorised Representative

Representatives Full Name

Relationship to patient