EPS Nomination

Title*

First Name*

Last Name*

Phone (Home)*

Phone (Mobile)*

Email Address*

Date of Birth*

Address Line 1*

Address Line 2

Address Line 3

Postcode*

GP Details*

Are you exempt from paying?*
—Please choose an option—NoYes

By ticking this box you are consenting to your future prescriptions being sent electronically to Rex Pharmacy. We will then dispense your prescriptions and deliver them to you. You can change this nomination at any time.

I accept