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IMPORTANTTo read the national and local advice about coronavirus, please click
HERE
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Choose Sarum Pharmacy
Nominate us to be the pharmacy that receives your prescriptions electronically from your GP and then choose where you want to collect them.
You can choose Sarum Pharmacy to receive your repeat prescriptions electronically. Please fill in and submit the form below.
First Name
Surname
Street Address
Town
Postcode
NHS Number
Preferred Location Pick Up Point
Avon Valley Practice - Upavon
Telephone Number (pref mobile)

We will use your mobile number to send you text messages to: 

  • Tell you when your medication is ready for collection
  • Ask you to contact us regarding any medication (and if we've not been able to speak with you)
  • Update you on the availability of your medication 
  • Arrange payment of your prescription if you pay (remember it is now £9.15 per Medication from 01/04/2020)

Please be reassured that we will not share your personal information nor contact you for marketing purposes. 


I pay for prescription charges.
I do not pay for prescription charges.
If you do not pay prescription charges please tell us why (tick the relevant option below).
I am 60 years of age or over OR I am under 16 years of age (unless your date of birth is printed on the form)
I am 16, 17 or 18 AND in full time education
I have a maternity exemption certificate
I have a medical exemption certificate
I have a Prescription Pre-Payment certificate
I have a Prescription exemption certificate issued by the Ministry of Defence
I have an H2 (full help) certificate
I receive Income Support OR income related Employment and Support Allowance
I receive income based Jobseeker's allowance
I have a Tax Credit Exemption certificate
I have Pension Credit/Guarantee Credit (including partners)
I receive Universal Credit AND meet the criteria. Find out more at www.nhsbsa.nhs.uk/UC
Tell us your exemption certificate number
Please tell us the expiry date of your exemption certificate
The information I have given is correct and complete and I confirm proper entitlement to exemption.

I understand that if I falsely claim, I may be issued a Penalty Charge Notice, and I may have to pay up to £100 – as well as my prescription charge(s).

I understand that the NHS Business Services Authority may use and share my information within the NHS and with relevant Government bodies to check for fraud and mistakes.
Find out more at: www.nhsbsa.nhs.uk/yourinformation

I understand that:
  • It is my responsibility to ensure my exemption details remain correct and in date
  • I am required to inform Sarum Pharmacy of any changes to my telephone number and medical exemption including expiry

I confirm I wish to register with Sarum Pharmacy for Provision of my repeat medication and agree to be contacted by telephone/text message (please sign and date)

I agree
Send
CONTACT
Sarum Pharmacy, The Portway Centre, Old Sarum Park
Old Sarum, Salisbury
Wiltshire
SP4 6EB
01722 442786
Contact Us
INFORMATION
Registered in : England and Wales Number:- 0562954
Premises GPhC: 1105314
Superintendent Pharmacist
Philip Harris (2027281)
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