Private Prescription Request Form 1 Your Details2 Prescription Items3 Your Consent Please call us on 0121 294 1141 Monday - Friday 9 - 5pm for a competitive price for Private Prescriptions. Getting started is simple, you just need to tell us the details of the items that you would like to order from your PRIVATE prescription, and give us some simple registration details. We will then request your prescription from your Doctor. Once we have obtained your prescription we will dispense and deliver it directly to your nominated address. This can be a home or work address. Please ensure you complete ALL of the sections marked with an * otherwise the form cannot be accepted. Name First Last Email (to receive confirmation of your request)* Enter Email Confirm Email Phone Number*Address* Street Address Address Line 2 City ZIP / Postal Code Date of Birth* GP DetailsGP's Name*GP's Address* Street Address City ZIP / Postal Code GP's Phone Number* Prescription Items*Description (eg Atenolol)Strength (eg 50mg)Quantity (eg 28 Tabs) Additional InformationPlease list any other medicines below. How would you like to pay for your prescription?*Pay onlinePay on DeliveryPatient Consent*Prescription collection and delivery service required. I authorise 'Five Ways Pharmacy' to collect my prescription from my surgery named above. Electronic prescription receipt and delivery required. Patients Signature - Please tick this box to act as your signature.* Please enter today's date* Fill in the amount to pay for your prescription - contact us to find out the amount This iframe contains the logic required to handle Ajax powered Gravity Forms.