Arc Pharmacy

PATIENT CONSENT FORM
Please complete this form as fully as possible if you wish to register for either the Collection Service, Repeat Prescription Service or the Collection & Delivery Service* operated by ARC Pharmacy.

Once completed click on the SUBMIT button to send us your details.

Click Here to PRINT the Patient Consent Form.

*All deliveries are at the discretion of the pharmacist.

* Required Fields

Name:

Address 1:

Address 2:

Postcode:

Date of Birth:

DD	MM	YYYY
			*

Email:

Telephone No:

(Your telephone number will only be used if there is a problem with your prescription.)

I give my permission to:

(Select pharmacy)

ARC Pharmacy, Portholme Road
ARC Pharmacy, Scott Road

Collect my prescription

Yes

Order repeat prescriptions

Yes

Deliver dispensed medicines to my home

Yes	No

Doctors Name:

Surgery:

Prescription Type:

Additional Comments:

Date Prescription will be ready for collection:

Requested delivery date:

(Please note that the delivery service is at the discretion of the pharmacist.)

Click here for terms and conditions

Click Here to view our opening Times.
Now open until 8PM on Mondays at our Portholme Road Branch.

Have difficulty collecting your prescription?

Haven’t got time to wait for your prescription to be dispensed?

Then why not take advantage of our free prescription collection, repeat prescription collection and delivery* services.

Click here for details on Collection and Delivery services.

Chesty cough?

Bad cold?

Why not relieve your symptoms with our famous Special Bronchial Mixture made on the premises.

Ask in store for advice.

Going on holiday…unsure of which health precautions to take?

Come in and visit us at ARC Pharmacy for advice.

Click here for your personal holiday checklist.