Express Prescription Collection Locker Request Form

NOTE: There may be some medicines which may not be suitable to be collected from 24/7 Collection Lockers such as controlled drugs, refrigerated or bulky items.

Select your local Pharmacy

Branches(Required)

Are you currently registered with this pharmacy for our prescription collection service?(Required)

Yes

Prescription Collection

We offer the convenience of collecting your prescription directly from your GP surgery and notifying you when it's ready for collection from our express collection locker. Simply provide us with your surgery details, and we will organise this for you.

Would you like to register for our prescription collection service?(Required)

Yes

Surgery Name(Required)

My GP is Dr:(Required)

Personal Details

Name(Required)

Title First Name Last Name

Address(Required)

Street Address Address Line 2 City Postcode

Date of Birth(Required)

You must provide us with your mobile number as it is required to send an SMS text message with a unique PIN number each time you have a prescription ready for uplift from the 24/7 Collection Locker. This service does not offer a reply facility to enable patients to respond to texts directly.

Mobile Phone Number(Required)

Confirm Phone Number(Required)

Name of account holder for mobile phone(Required)

I confirm this is my own personal mobile phone and understand that I cannot receive messages regarding prescriptions for a family member without consent.

Agreements(Required)

To register for this service you must agree to the below

I am the patient named above / carer of the patient named above

I give permission to Davidsons Chemist to collect and process my prescription and make it available for collection from the 24/7 Prescription Collection Locker

I confirm that I will advise the Pharmacy if I change my mobile number.

I consent to receiving text messages from Davidsons Chemists regarding my medication.

Phone

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