Order your Prescription - Evergreen Pharmacy

Order Prescriptions

Order your prescriptions through our online form and get them delivered directly to your door. A member of our team will contact you for payment if required.

Personal details

Title

First Name*

Last Name*

Phone (Home)

Phone (Mobile)

Email Address*

Date of Birth*

Address

House number & street*

Apartment, flat etc.

Town / City*

County*

Postcode*

Exemption

Are you exempt from prescription payments? Tick "NO" if you pay for your prescriptions or "YES" if you do not.

The NHS regularly carries out counter fraud checks when patients say that they are exempt from prescription charges. The NHS also requires us to ask you for evidence that you are exempt from paying prescription charges for some types of exemption and to notify them if we do not see this evidence. The NHS can fine you if you wrongly claim to be exempt from paying for your prescriptions even if it is a mistake.

NoYes

Please upload proof if you have not already done this previously

How many prescriptions do you need to pay for?

Surgery details

Name of surgery

Name of GP

Prescription details

Please write down the Name, Strength and Quantity of each medicine you require e.g. Atenelol Tablets 25mg x 28. Only order what you need.*

Please sign here

Order Prescriptions

Personal details

Address

Exemption

Surgery details

Prescription details

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