Get Started Please enable JavaScript in your browser to complete this form.I am completing this form on behalf of ...MyselfSomeone elseNote: I have consent to sign up this patient and understand PillSorted may need to contact me to confirm consent and detailsYour Title * Miss.Mrs.Mr.Your First Name *Your Last Name *Your Email *Your Phone *Patient InformationPatient Title * Miss.Mrs.Mr.Patient First Name *Patient Last Name *Patient Email *Patient Phone *Date of Birth *MM123456789101112/DD12345678910111213141516171819202122232425262728293031/YYYY202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Address *Address Line 1Address Line 2CityState / Province / RegionPostal CodeGP Surgery Name (if available at hand)Exemptions (Do you pay for your prescriptions?) *Yes, I pay for my prescriptions(A) Age Exempt (Under 16 or over 60) (B) Full-time Students aged 16, 17 or 18(D) Maternity Exemption Certificate(E) Medical Exemption Certificate(F) Pre-payment certificate (PPC)(G) Prescription Exemption Certificate issued by the Ministry of Defence(L) HC2 (full help) certificate(H) Income Support (IS)(K) Income-based Jobseeker’s Allowance (M) Tax Credit exemption certificate(S) Pension Credit Guarantee Credit (U) Universal CreditConsent *I am nominating PillSorted as my NHS pharmacy I agree to PillSorted accessing my Summary Care RecordI agree to PillSorted providing my medicationConsent *I am providing consent for above patient and am authorised to provide consent on their behalfI am nominating PillSorted as above patient PharmacyI agree to PillSorted accessing above Summary Care RecordI agree to PillSorted providing above medicationMessageSubmit