Prefix—Please choose an option—MrMrsMissMsOther

First Name

Last Name

Gender—Please choose an option—MaleFemale

Date of Birth

Your email

Mobile Number

Phone Number

NHS Number (if Known)

Address, No. / Street,

City/Town

Postcode

Prescription payment / exemption status—Please choose an option—I pay for my prescriptionsI am 60 years of age or over or 16 years of age or youngerI am 16, 17 or 18 and in full time educationI have a Maternity exemption certificateI have a medical exemption certificateI have a prescription prepayment certificateI have a prescription exemption certificate issued by the Ministry of DefenceI have a HC2 (full help) certificateI receive Income Support or Income-related Employment and Support AllowanceI receive income-based Jobseeker AllowanceI have a Tax Credit exemption certificateI have a Pension Credit Guarantee (including partners)I receive Universal Credit and meet the criteria for free prescriptions

Exemption certificate number (if applicable)

Exemption certificate expiry date (if applicable)

Select Free delivery / Collection option—Please choose an option—Free deliveryCollection