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IMPORTANTRead the national and local advice about coronavirus, please visit GOV.UK
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Registration Form For Free Delivery
Please complete the form below and submit.
Customer Information
First Name
Middle Name(s)
Surname
Address Line 1
Address Line 2
Town
Postcode
Gender
male
Date of Birth - dd/mm/yyyy
Telephone
Mobile
Doctor's Information
Surgery Name
Address Line 1
Address Line 2
Town
Postcode
Payment and Exemption
I pay for prescription charges.
If you do not pay prescription charges please tell us why (tick the relevant option below).
I am under 16 years of age
I am a full time student aged 16-18
I am 60 years of age or over
I have a valid maternity exemption certificate
I have a valid medical exemption certificate
I have a valid prescription pre-payment certificate
I have a valid war pension certificate
I am named on a current H 2 Charges certificate.
I am prescribed free of charge contraceptives
I receive income support
I receive income based job seekers allowance or universal credit
I am entitled too or named on, a valid NHS tax credit exemption certificate
I have pension Credit (Guarantee Credit) paid on it's own or Pension Credit (Guarantee Credit with Savings Credit)
I have a partner who gets pension credit (guarantee credit)
My Authorisation and Consent
  • I understand that my registration with you is subject to Joydens Wood Pharmacy standard terms which i can view at www.jwpharmacy.co.uk
  • If I have stated I am exempt from payment, I confirm I am properly entitled to exemption and that if my entitlement changes, I will tell you immediately on 01322 522 711.
  • I understand that if i do not, you may take appropriate action.
I agree
I consent to my prescription:
  • being collected from my GP Surgery
  • being from my GP Surgery using the Electronic Prescription Service (EPS) to Joydens Wood Pharmacy
  • being to delivered to the address stated on this form
  • my contact details being used for communication purposes only in relation to matters concerning prescripition collection or delivery
I agree
Send
CONTACT
2 Birchwood Parade, Woodside Drive
Joyden's Wood
Kent
DA2 7NJ
01322 522 711
Contact Us
INFORMATION
Company Registration
N/A
Premises GPhC Number:
1032690
Superintendent Pharmacist
Jasminder Wasu (2030585)
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