> Form – Express Prescription Collection Locker Request Form

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

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

Personal Details

Name(Required)
Address(Required)
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.
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
This field is for validation purposes and should be left unchanged.