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Sign up to PillTime

Please fill in your details below, if you are signing someone else up to the service, please enter the patient's details below.

Patient Information

Date of Birth

Address

Exemption


Do you need your prescription in the next 7 days? If so tick this box.

It can take up to 7 days for us to deliver your first prescription. You'll need to get them from your local pharmacy in your usual way, this time. we will wait for 7 days before informing NHS England that we will be your pharmacy and provide you with your medication when it is next due.


Consent


By completing this form you are nominating PillTime as your NHS pharmacy. Please indicate whether you are providing consent for yourself or are authorised to provide consent for someone you care for


I am completing this form on behalf of...



I have consent to sign up this patient and understand PillTime may need to contact me to confirm consent and details

I agree to the terms and conditions of the services provided by PillTime

I agree to PillTime accessing my Summary Care Record

I agree to PillTime providing my medication

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