Consent Form (Repeat Delivery)

Patient Details

Name

Date of Birth

Address

Phone

Please give the name of the pharmacy (chemist) where you normally have your prescriptions dispensed (if applicable).

Pharmacy Name

I am the above named patient or patients’ carer. By clicking to submit this form, I agree that iPharm will make arrangements for all my future prescriptions to be dispensed in this way including Electronic Repeat Dispensing. If I wish to change this arrangement I will inform iPharm UK.

I wish to nominate iPharm UK Ltd to:

  • Order my prescription from the surgery.
  • Collect my prescription from the surgery.
  • Deliver my medication to me.

Name of medication(s) (if known):

Medication/s are due on (if known):

Doctors Details

GP Name

GP Address

GP Phone Number