Please confirm which evidence of registration with a General Practice you will be presenting below:
    Medical CardRX Request SheetPMR or Other Pharmacy RecordConfirmation of Registration DocumentSurgery Confirmed Registration
    Who referred you to our Minor Ailment Service?
    GP SurgeryA&ENHS 111GP Surgery based PharmacistOut of Hours Service
    Self ReferralPharmacy TeamOther

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

    Specify Gender *

    MaleFemale

    Details of Symptoms Reported

    Please indicate your local surgery
    Manor House Surgery

    Bridlington

    Bridlington

    Flamborough

    Flamborough

    Field House Surgery

    Bridlington

    Bridlington

    Flamborough

    Flamborough

    Wolds View Surgery

    Wolds View Surgery

    Wolds View Surgery

    Station Avenue Medical Centre

    Practice 1

    Practice 1

    Practice 2

    Practice 2

    Practice 3

    Practice 3

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

    GP Surgery

    GP Surgery

    Practice Nurse

    Practice Nurse

    Walk-in Centre

    Walk-in Centre

    Pharmacy Purchase

    Pharmacy Purchase

    A&E

    A&E

    Out of Hours Service

    Out of Hours Service

    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.