SG Court Pharmacy Group

NHS Prescription Request

Please complete the following form to submit your prescription request. Unless you are exempt, you will be charged £7.20 per item on your prescription. If your item is to be delivered, the driver must be paid in cash for all items delivered. Please note we can only deliver your medication to the home address specified on your prescription. * - denotes required information that must be entered.

SG Court branch:

Do you require delivery *?

Yes

No

Are you exempt from prescription payments *?

Yes

No

Please choose the total number of prescription items you require.

Drug name *:		Drug strength *:
Drug name *:		Drug strength *:
Drug name *:		Drug strength *:
Drug name *:		Drug strength *:
Drug name *:		Drug strength *:
Drug name *:		Drug strength *:
Drug name *:		Drug strength *:
Drug name *:		Drug strength *:
Drug name *:		Drug strength *:
Drug name *:		Drug strength *:
Drug name *:		Drug strength *:
Drug name *:		Drug strength *:
Drug name *:		Drug strength *:
Drug name *:		Drug strength *:
Drug name *:		Drug strength *:
Drug name *:		Drug strength *:
Drug name *:		Drug strength *:
Drug name *:		Drug strength *:
Drug name *:		Drug strength *:
Drug name *:		Drug strength *:

+ add another prescription item

Prescription total: £7.20

(some items may incur more than one charge. We will advise you of this on delivery)

SG Court Pharmacy Group

NHS Prescription Request

SG Court branch:

Do you require delivery *?

Yes

No

Are you exempt from prescription payments *?

Yes

No

Drug name *:

Drug strength *:

Drug name *:

Drug strength *:

Drug name *:

Drug strength *:

Drug name *:

Drug strength *:

Drug name *:

Drug strength *:

Drug name *:

Drug strength *:

Drug name *:

Drug strength *:

Drug name *:

Drug strength *:

Drug name *:

Drug strength *:

Drug name *:

Drug strength *:

Drug name *:

Drug strength *:

Drug name *:

Drug strength *:

Drug name *:

Drug strength *:

Drug name *:

Drug strength *:

Drug name *:

Drug strength *:

Drug name *:

Drug strength *:

Drug name *:

Drug strength *:

Drug name *:

Drug strength *:

Drug name *:

Drug strength *:

Drug name *:

Drug strength *:

+ add another prescription item

Prescription total: £7.20

Special instructions / requests:

Full name *:

Address Line 1 *:

Address Line 2:

Town / City:

County:

Postcode *:

Email Address *:

Telephone number *:

Your doctor's name *:

Address of your doctor's Surgery *: