Medicine Supply Record Form - Nhs Community Pharmacy Emergency Supply Service (Page 2 of 2) in pdf

Medicine Supply Record Form - Nhs Community Pharmacy Emergency Supply Service Page 2

The patient doesn’t have to pay because he/she:

Part 1

is under 16 years of age

Pharmacy use only

is 16, 17 or 18 and in full-time education

is 60 years of age or over

has a valid maternity exemption certificate

has a valid medical exemption certificate

Evidence not seen

has a valid prescription pre-payment certificate

is named on a current HC2 charges certificate

is entitled to, or named on, a valid NHS Tax Credit Exemption Certificate

or his/her partner gets Income Support

gets income-based Jobseeker’s Allowance

gets Universal Credit

gets income-related Employment and Support Allowance

or his/her partner gets Pension Credit Guarantee Credit

gets Employment and Support Allowance

I declare that the information I have given on this form is correct and complete.

I understand that if it is not, appropriate action may be taken. I confirm proper entitlement to

exemption from prescription charges.

To enable the NHS to check I have a valid exemption and to prevent and detect fraud and

incorrectness, I consent to the disclosure of relevant information from this form to NHS England,

the NHS Business Services Authority, the Department of Work and Pensions and Local

Authorities.

Part 2

I have paid £

Now sign and fill in Part 3.

the patient’s guardian

I am

the patient

(Cross ONE box)

Part 3

I agree that the information on this form can be shared with:

 My/the patient’s GP practice to help them provide care to me/the patient

 NHS England (the national NHS body that manages pharmacy and other health services)

to allow them to make sure the service is being provided properly by the pharmacy

Signature

Date

If different from overleaf, add your name and address below

Name

Address

Postcode

If you hadn’t received a supply of your medicine from the pharmacy, what would you have done?

Gone without my

Contacted my GP

Contacted the out

Visited A&E or an

medicine

practice

of hours GP service

urgent care centre

Confidential

Medicine Supply Record Form - Nhs Community Pharmacy Emergency Supply Service Page 2

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