Britannia Pharmacy
Free Repeat Prescription Collection Registration Form
Making Life Easier For You
We will personally pick up your prescription from your surgery and have your
medication ready for collection at your convenience.
Please complete the details below to register for our
Free Prescription Collection Service and take it in to your nearest
Britannia Pharmacy Branch.
I would like Britannia Pharmacy to collect my prescriptions from the surgery for me or for
the surgery to electronically transfer the prescription to Britannia Pharmacy.
Your Full Name ………………………………………………………………………...
Full Address ……………………………………………………………………………
………………………………………………………………………………………….
………………………………………………………………………………………….
Telephone Number …………………………………………………………………….
Your GP ………………………………………………………………………………..
Surgery Address ………………………………………………………………………..
………………………………………………………………………………………….
Signed ………………………………………… Dated ………………………………..
I will let you know if I wish to change this arrangement
Thank you
If you have any questions or any individual requirements, please speak to one of our staff, or call
our dedicated Prescription Collection and Delivery Line on 0845 872 2788 (Local Rate), or email :
CustomerServices@britanniapharmacy.com.