EPS Nomination

Please fill the form below to nominate Roundhay Pharmacy for your Electronic Prescription Service.

Please allow 48 hours for Nomination changes to complete before making a new prescription request.

Patient First Name*

Patient Last Name*

Patient Email Address*

Patient Phone Number*

Patient Date of Birth*

NHS Number (Optional)

Patient Address Line 1*

Patient Address Line 2 (Optional)

Patient Address Line 3 (Optional)

Patient Town/City*

Patient Country (Optional)

Patient Postcode*

Select One
PatientPatient Representative

Representative Name

Representative relation to patient

I am the patient named above/carer of the patient named above. Nomination has been explained to me and I have also been offered a leaflet that explains nomination. Click here to download/print.

I would like to nominate Roundhay Pharmacy as my nominated pharmacy for dispensing prescriptions issued by the NHS Electronic Prescription Service.

By clicking Nominate Now you agree to our Terms and Conditions and you have read our Privacy Policy.

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Please fill the form below to nominate Roundhay Pharmacy for your Electronic Prescription Service.

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