Please complete as many fields as possible.
Fields marked * are mandatory.

When required, you can email pictures to picture@pills2u.co.uk

Pills2u will automatically be nominated to receive and access this person's
Electronic Prescriptions and Summary Care Records unless notified otherwise

Title:*
First Name:*
Middle Name:
Last Name:*
Date of Birth:*
if resident is under 60yrs,
please detail exemption.
CLICK HERE FOR EXEMPTION LIST
Home:*
Floor:
Room:
NHS No.:*
Allergies:
if none known,
please leave as 'none known'
Doctors name:
Surgery:*
your name