EPS Nomination Form

Nominate our pharmacy by completing the form below for your prescriptions to be sent electronically from your GP to us for dispensing. If you have any questions, please contact our team or visit us at the pharmacy.

First Name

Last Name

Date Of Birth

NHS Number (If Known)

Phone

GP Surgery Name and Address

Consent

I authorise this pharmacy to order, collect and deliver my repeat medications.

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Information

Owner: Rotamol Ltd

Premises GPhC Number: 1041016

Superintendent: Mobolade Ososami GPhc: 2050556

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EPS Nomination Form