Collection Locker 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)

Please Select

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

Yes

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)

Mobile Number Owner (if different)(Required)

If the mobile number provided is not registered to the patient, please enter the name of the account holder and their relationship to the patient.

To use our 24/7 Prescription Lockers, we need your mobile number to send a PIN when your prescription is ready.(Required)

I consent to Davidsons Chemists collecting and processing my prescription, making it available via the 24/7 Prescription Collection Locker, and contacting me by text regarding my medication. I will inform the pharmacy if my mobile number changes.

I consent to my prescriptions being stored in the locker and to receiving text messages. I will inform the pharmacy if my mobile number changes.

Name

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