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Your Personal Details

First Name

Last Name

Date of Birth

Password

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NHS Number

Your Contact Details

Address Line 1

Address Line 2

City

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Post Code

Mobile

Telephone Number

Your Doctor Details

Surgery Name

Doctor Name

Surgery Address Line 1

Surgery Address Line 2

Surgery City

Surgery County

Surgery Post Code

Surgery Telephone Number

Your Consent

Authorisation of Service

I authorise Smarta Healthcare to collect and dispense my prescriptions for me from my doctor's surgery

Repeat Prescription Order & Delivery Service

Electronic Prescription Service

Monitored Dosage Systems Service

By providing the details above you agree to Smarta Healthcare to contact you about your chosen service. You also agree for us to act on your behalf to liaise with your surgery either by phone, post, in person or electronically and collect your prescription either in person, post or electronically or by Electronic Prescription Service (participating surgeries only).

Contact Permission

We may send you exclusive offers or latest information from Smarta Healthcare by email, post SMS and other means of electronic. We always treat your personal information with care and will never sell to other third party companies for marketing purposes.

Yes please, I will like to hear about services, health and well-being information

No thanks, I do not want to hear about the services or health and well-being information