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(FP92A) Application Prescription charge exemption
You can use this form to request for free prescriptions if you are entitled to this on the NHS
** Please allow 2 working days before collecting your prescription. The surgery will verify your request against your records before completing
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YOUR DETAILS
Please include your latest personal details so that we can contact you if necessary
Your Full Name
*
Your answer
Your Date of Birth
*
Please include your DOB in the form of DD/MM/YYYY i.e 01/01/1980
MM
/
DD
/
YYYY
Your MOBILE number
*
If we need to contact you to clarify your answers
Your answer
Your EMAIL number
*
If we need to contact you to clarify your answers
Your answer
I declare that, I have:
*
Tick the options that describes your personal medical problems.
Diabetes mellitus on medication (not diet control only)
A permanent fistula (e.g. colostomy, ileostomy, laryngostomy) requiring continuous surgical dressing or appliance
Epilepsy for which I need continuous anti-convulsive therapy/medication
Hypothyroidism (also known as Myxoedema) requiring thyroid hormone replacement i.e. levothyroxine
Hypoparathyroidism
Diabetes insipidus or hypopituitarism
Hypoadrenalism (i.e. Addison's disease) for which specific substitution therapy is essential
Myasthenia gravis
Continuing physical disability which means
Cancer: Including the effects of cancer or effects of current or previous cancer treatment
Continuing physical disability which means I cannot go out without the help of another person
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