Buckden Pharmacy, No 8 Hunts End, Buckden. St Neots PE19 5SU Call Us On : 01480 810077 Please fill in the form below for free prescription delivery 1. Patient Details First Name Last Name Email Preferred Phone Number Gender MaleFemale Date of Birth NHS Number (If Known) Mobile Telephone Number Address House Name / Number Street Name City/Town Post Code 2. GP Details Surgery Name City/Town Electronic Prescription Service -- Is Electronic Prescription Service Available at your GP? --YesNoNot Sure Click here for further information regarding EPS (Electronic Prescription Services) Summary Care Record SCR Acceptance Tick box to give consent to allow Buckden Pharmacy access to your Summary Care Record What is a Summary Care Record (SCR)? The NHS SCR is an electronic summary of key clinical information (including medicines, allergies and adverse reactions) about a patient, sourced from the GP record. It is only used by authorised healthcare professionals, with the patients’ consent, to support their care and treatment. 3. Exemption Details Do You Pay For Your Prescriptions YesNo I don't pay because: I am under 16 years of age.I am 16, 17, or 18 and in full-time education.I am 60 years of age or over.I have a valid maternity exemption certificate.I have a valid medical exemption certificate.I have a valid prescription pre-payment certificate.I have a valid War Pension exemption certificate.I am named on a current HC2 charges certificate.I was prescribed free of charge contraceptives.* I get Income Support or income related Employment and Support Allowance.*I get income-based Jobseeker's Allowance.* I am entitled to, or named on, a valid NHS Tax Credit Exemption Certificate.* I have a partner who gets Pension Credit guarantee credit (PCGC). Consent to Repeat Online Prescriptions I am the patient or the patients' representative as named above. I confirm by ticking this box, that I am giving consent to nominate Repeat Online Prescriptions (trading as Buckden Pharmacy) as my pharmacy to provide my medication. Consent to Repeat Online Prescriptions It is my responsibility to inform Repeat Online Prescriptions if any of the above exemption details change, as an incorrect declaration may result in penalty charges by the NHS Business Service Authority. Prescription Delivery Consent I consent to the delivery of my prescription by Buckden Pharmacy. THIS FORM IS GDPR COMPLIANT To provide this service we will need to collect some personal data about you, which may include sensitive information about your health. By registering to use our pharmacy services you agree that we may use this information to give you the best care and advice we can. Please see our Privacy Policy to see how we protect and manage your submitted data. We will never sell your information to third parties. SUBMIT FORM
