To register as a patient with the pharmacy, please complete this form. Your information will be securely sent to the pharmacy.

By completing the form below you are nominating Pharmacy@Roxton as your NHS pharmacy.

As a responsible pharmacy we need confirmation from you that we can access details such as your Summary Care Record. This will enable us to see your current prescribed medication and known allergies.

By continuing, you agree to share your details with Pharmacy@Roxton in accordance with our privacy policy.

What is your full name? *

What is your gender? *

Male Female Prefer not to say

What is your date of birth? *

What is your email address? *

What is your telephone number? *

What is your address? *

What is your GP surgery? *

Are you exempt from paying for your prescriptions? *

Yes No

Submit your registration request