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FREE DELIVERY* when you spend £20 or more!

*exclusions apply
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Prescription details

Fields marked * must be completed

Who the prescription is for

  • * Please select who the prescription is for:

    Choose whether the prescription is for yourself or somebody else.

  • * Confirm that you have permission to place this order on behalf of the patient:

    To order a prescription for someone else you must have their permission.

  • Please enter your full name (not the name of the person the prescription is for).

  • Your NHS number can be found on your registration card, which you receive when you sign up with a GP. Please call NHS Direct on 0845 4647 for more guidance.

  • Please select your title from the drop down menu.

  • Please enter the first name of the person the prescription is for.

  • Please enter the last name of the person the prescription is for.

  • * Patient date of birth

    Please enter the date of birth of the person the prescription is for.

  • * Patient gender

    Please enter the gender of the person the prescription is for.

Prescription items

  • Some prescriptions may contain a dual charge. To view a list of such items, please click here. For further assistance please contact our customer care team on 0844 262 9992 (9am to 6pm, Monday to Friday).

Prescription payment

  • * Please select which statement applies

    Select this option if the person the prescription is for does not qualify for free prescripions.

    Select this option if the person the prescription is for qualifies for free prescriptions, and indicate how by choosing the reason for the exemption from the drop down menu (this information should be indicated on your prescription).

    Select this option if the person the prescription is for qualifies for free prescriptions, and indicate how by choosing the reason for the exemption from the drop down menu (this information should be indicated on your prescription).

Additional details

  • Enter your additional details.

Contact details

  • If your correct email address doesn't already appear here please enter an email address we can reach you on.

  • The pharmacist may need to contact you about your prescription (please enter a number on which you will be available Monday - Friday, between 9am - 6pm)

  • Please select one of the security questions from the drop down menu.

  • Please select a memorable answer for your security question. You may be asked for this to check your identity if you're contacted by the Co-operative Pharmacy, so it should be something you can easily recall.

  • Please enter your mobile number in case a customer care representative needs to contact you about your prescription.

Medical Conditions

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