Please register your details for our prescription collection & delivery service. First Name* Last Name* Date Of Birth* Address Line 1* Address Line 2 City Post Code* Email* Contact number* GP Details (Name & Address) Are you exempt from prescription charges?* Yes (please provide details below)No Please select below your exemptionis under 16 years of ageis 16, 17 or 18 and in full-time educationis 60 years of age or overhas a valid maternity exemption certificatehas a valid medical exemption certificatehas a valid prescription pre-payment certificatehas a valid War Pension exemption certificateis named on a current HC2 charges certificatewas prescribed free-of-charge contraceptivesgets Income Support or income-related Employment and Support Allowancegets income-based Jobseeker's Allowanceis entitled to, or named on, a valid NHS Tax Credit Exemption Certificatehas a partner who gets Pension Credit guarantee credit (PCGC) By using this form you agree with the storage and handling of your data by this website. Your browser does not support JavaScript!. Please enable javascript in your browser in order to get form work properly.