Patient Name *

Patient Address *

Patient Town *

Patient Postcode *

Patient Phone *

Patient's Surgery *

I am the (select one)* I am the (select one)PATIENTPATIENT REPRESENTATIVE

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. Also available to download/print here: www.hscic.gov.uk/epspatients

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

I confirm that I have made my nomination of my own free will and have not been influenced or given a gift to select a particular nomination and that I can change my mind at a later date