Full Name

Phone Number

Email Address

Date of Birth

Address Line 1

Address Line 2

Address Line 3

Postcode

GP Details

Are you exempt from paying?
Select an optionYesNo

Upload proof of exemption (jpg, png or pdf)

By ticking this box you are consenting to your future prescriptions being sent electronically to The Pharmacy at Mayfair and Clinic. We will then dispense your prescriptions and deliver them to you. You can change this nomination at any time.

I accept