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Name(Required)

First Name Last Name

Date of Birth(Required)

Address(Required)

Street Address City / Town Post Code

Email(Required)

Phone(Required)

How would you like to receive your medication?(Required)

Original packs (boxes and bottles)

Pouches

Blister/Dosette Box

GP Search(Required)

Enter postcode, surgery name or town to search OR select GP surgery not listed

Can't find your GP surgery?

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I understand that(Required)

I understand that my medication will only be packed into a compliance aid if I have 3 or more medicationns.

The Legal Stuff(Required)

I agree to the Terms & Conditions and Privacy Policy

Please sign below(Required)

I agree to make Capsule Pharmacy my chosen pharmacy. This means Capsule Pharmacy retain my repeat prescription re-order slip, request prescriptions from my surgery and collect prescriptions on my behalf either in person or by electronic transfer.