24/7 Prescription Collection Point

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

To register, please complete the form below:

1. Please nominate Gowerton Pharmacy at your GP surgery as your pharmacy of choice.
2. We can then collect your NHS prescription direct from your GP surgery.
3. We will text you to collect your prescription from our 24/7 point at your convenience.

No rushing. No Queues. Leave the stress to us!

Email *

TITLE *

FIRST NAME *

LAST NAME *

PLEASE INSERT THE PATIENT'S DATE OF BIRTH *

YYYY

PHONE (MOBILE) *

ADDRESS LINE 1 *

ADDRESS LINE 2

ADDRESS LINE 3

POSTCODE *

NAME OF SURGERY (PLEASE SELECT) *

Estuary Group Practice (Gowerton Medical Centre, Penclawdd Health Centre, Pen-Y-Bryn Surgery)

Fforestfach Medical Centre

Ty'r Felin Surgery

Princess Street Surgery

Other:

Please note, we accept prescriptions from all surgeries, but at present we can only collect from the surgeries above. You can drop off your prescriptions in-store to us or via our letterbox. We will process them and place them in our 24/7 collection point for you to collect at your convenience.

IF YOU ARE NOT THE PATIENT, PLEASE SPECIFY YOUR RELATIONSHIP TO THE PATIENT

PLEASE TICK SERVICES REQUIRED *

I would like to sign up to the 24/7 Collection Point

I would like you to collect my prescription from the surgery (Please ensure to nominate Gowerton Pharmacy to your surgery)

Required

Please note patients signing up to the 24/7 Collection Point are responsible for collecting their refrigerated lines promptly. Gowerton Pharmacy cannot be held responsible if the conditions are exceeded.

Submit

Clear form

Never submit passwords through Google Forms.

This form was created inside of Gowerton Pharmacy. Report Abuse

Forms