Insync Pharmacy - Registration

please fill in all three sections of the form below if you would like us to collect your repeat prescriptions

Name Title First name Last name Date of Birth Address Number & Street City Postcode Phone Number E-mail address

Surgery Details Surgery Doctors Name

Authorisation I wish to nominate a member of Insync Healthcare Pharmacy to order and collect my prescription on my behalf and to make arrangements for all my future prescriptions to be dispensed this way.
This will include electronic transfer of my prescription and allows my dispensed medicines to be delivered directly to my home address.
I also give my consent in receiving repeat dispensing prescriptions and for Insync Healthcare Pharmacy to view my patient record at the surgery.
If I wish to change this arrangement I will inform Insync Healthcare Pharmacy. Date

If you prefer you can click here to download the registration form and hand it it to us personally

freephone 0800 988 3003