PillSorted - Get Started (NHS)

I am completing this form on behalf of ...

Note: I have consent to sign up this patient and understand PillSorted may need to contact me to confirm consent and details

Your Title *

Your First Name *

Your Last Name *

Your Email *

Your Phone *

Patient Title *

Patient First Name *

Patient Last Name *

Patient Email *

Patient Phone *

Date of Birth *//

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

GP Surgery Name (if available at hand)

Exemptions (Do you pay for your prescriptions?) *

Consent *

Consent *

I am providing consent for above patient and am authorised to provide consent on their behalf
I am nominating PillSorted as above patient Pharmacy
I agree to PillSorted accessing above Summary Care Record
I agree to PillSorted providing above medication