EPS Nomination – Eastville Pharmacy

Please fill the form below to nominate Eastville Pharmacy for your Electronic Prescription Service.

The way the NHS provides prescriptions to patients is changing, with the Electronic Prescription Service, your prescription can be sent to us from ANY surgery in England. Nominate Eastville Pharmacy as your pharmacy of choice and your GP will send us your prescription electronically, saving you time from picking up your paper prescription from the surgery.

Patient First Name*

Patient Last Name*

Patient Email Address*

Patient Phone Number*

Patient Date of Birth*

NHS Number (Optional)

Patient Address Line 1*

Patient Address Line 2 (Optional)

Patient Address Line 3 (Optional)

Patient Town/City*

Patient Country (Optional)

Patient Postcode*

Select One
PatientPatient Representative

Representative Name

Representative relation to patient

I am the patient named above/carer of the patient named above. Nomination has been explained to me and I have also been offered a leaflet that explains nomination. Click here to download/print.

I would like to nominate Eastville Pharmacy as my nominated pharmacy for dispensing prescriptions issued by the NHS Electronic Prescription Service.

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