Patient Representative Nomination Form

Patient Representative Nomination Form

Please complete the below form to nominate us (Lawley Pharmacy) to receive your prescriptions from your doctors surgery electronically.

I am the Parent/Guardian/Carer of the patient named above (required)

I have read and understood the information on EPS nomination and I understand what I have to do:

I confirm that that I have made my nomination of my own free will and have not been influenced or given a gift to select a particular nomination:

I hereby nominate the above named Pharmacy, to be my dispensing site for Electronic Prescriptions:

nominate lawley pharmacy
01952 504666
Lawley Medical Practice, Farriers Green, Lawley, Telford, TF4 2LL
Opening Hours
Monday 8:45 am – 8:00 pm
Tuesday 8:45 am – 8:00 pm
Wednesday 8:45 am – 7:30 pm
Thursday 8:45 am – 7:30 pm
Friday 8:45 am – 8:00 pm
Saturday 9:00 am – 12:00 pm
Sunday Closed