Consent Form (Repeat Delivery)

Patient Details


Date of Birth



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