EPS Registration Form - Victoria Road Surgery

The Electronic Prescription Service (EPS) is a NHS service that allows us to send your prescription(s) directly to your chosen pharmacy. This paper-free prescription service means that you do not have to come into the surgery to collect your prescription.

We encourage all patients to register for this free service.

Please see more information about the electronic prescription service.

Are you completing this form on behalf of:

Yourself

Someone else (e.g. a child or dependent)

About the patient

Patient's Name

First Last

As it appears on the patient’s passport.

Patient's Current Postcode

‏‏‎ ‎

The one they used to register with the GP.

Patient's Date of Birth

Patient’s date of birth is required to verify their identity.

Patient's Sex

Male

Female

Other

As on the patient’s medical record.

About you

Relationship to the patient

Your Name

First Last

As it appears on your passport.

Your Current Postcode

‏‏‎ ‎

The one you used to register with your GP.

Your Date of Birth

Your date of birth is required to verify your identity.

Sex

Male

Female

Other

As on your medical record.

Your Phone Number Optional

The practice may use this number to contact you about your request

Your Email Optional

This email address can be used to contact you about your request. Please be aware that if you have given anyone else access to your email account they may see responses sent to you.

Pharmacy Details

Chosen Pharmacy is: Optional

Please specify which pharmacy you would like to receive your prescription at

Not sure where the closest pharmacy is?

Use the NHS Find a Pharmacy tool.

Email Optional

This field is for validation purposes and should be left unchanged.