pharmacyDIRECT
ORDER YOUR PRESCRIPTION

...the hassle-free pharmacy....

pharmacyDIRECT, Head Office, 202 Shirley Road,  Southampton   SO15 3FL tel/fax 023 8036 0095

Authority for pharmacyDIRECT (Arun Sharma Chemists) to Collect & Deliver my Prescriptions

Name

Address
Suburb
City
 
Postcode
Email
Telephone Number
Fax Number
Date of Birth
Doctor's Name
Surgery Address
Suburb
City
 
Postcode
Surgery Telephone Number
Surgery Fax Number
 

Declaration of Exemption

A. I am exempt from paying prescription charges.

PLEASE SELECT THE BOX YOU TICK    I tick box     on the back of the prescription form. I authorise you to complete the form on my behalf until further notice. It is my responsibility to inform you of any change in my exemption status.

 
B. I am not exempt from paying prescription charges.

Please complete the back of the prescription on my behalf and take the prescription tax from my credit/debit card, the details of which follow, and provide me with a receipt.
Card Holders Name                                 Issue number if given
   
Card Type                                               Card Number
 
Expiry Date
Month Year
Valid From Date
Month Year
I authorise pharmacyDIRECT (Arun Sharma Chemists) to order, collect & deliver my prescriptions and e-prescriptions. I will initiate the request by telephone, email, fax, mail or in person. Please complete the back of the prescription form on my behalf and if prescription charges are due from me please use the card details above.
Signed (Please re-type your full name)                     Dated
   
I accept your terms and conditions
 
 

Webmaster: arun@thedeal.demon.co.uk               Copyright Arun Sharma Healthcare plc 2000