Contact Number:

Date of Birth:


Britannia Branch ( 1st line address of branch ) :




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By submitting this form: You confirm that you are self-isolating or shielding and are unable to arrange a family member, friend, or neighbour to collect your medication, and therefore you authorise Britannia Pharmacy to arrange delivery of your medication.
I give consent to Britannia Pharmacy to nominate me to their pharmacy allowing them to receive my prescriptions electronically

 

Delivery Services during COVID-19
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Once you have requested you medication we will arrange delivery of your prescription within 24 hours of receiving your prescription from your GP.

Patients already registered on our home delivery service, prior to the Covid-19 crisis will continue to receive their deliveries as normal.

 

*Please complete all fields, If you experience any technical problems, please send a email to CustomerService@britanniapharmacy.com