Minor Ailments Service

Please confirm which evidence of registration with a General Practice you will be presenting below:

Who referred you to our Minor Ailment Service?

You’re almost there. Please complete the following relevent fields...

Details of Symptoms Reported

Please indicate your local surgery

If this scheme was not in place where would you have gone for advice/medication? (tick appropriate box)

Details of this prescription will be shared with your Doctor and the Local Clinical Commissioning Group for Audit Purposes. All information will be treated with the
strictest confidence and held in acordance with the Data Protection Act.

Consent for sharing information received? * YesNo

Note: YOU will be asked to show proof that you do not have to pay prescription charges. if you do not have proof, you will still get your free medicine
supply but checks will be made later to confirm your eligibility.

Exemptions: The patient doesn’t have to pay because he/she:

DECLARATION: I declare that the information I have given on this form is correct and complete and I understand that if it is not, appropriate action
may be taken against me. I confirm proper entitlement to exemption and for the purposes of checking this, I consent to the disclosure of relevant
information, including to and by the Inland Revenue and Local Authorities.