Nominate UsWe are glad you decided to nominate PillSorted as your NHS pharmacy, please fill in the form below and we will process your nomination request.Please enable JavaScript in your browser to complete this form.Select *I am completing this form on behalf of ...MyselfSomeone elseAddress *Address Line 1Address Line 2CityState / Province / RegionPostal CodeNote: I have consent to sign up this patient and understand PillSorted may need to contact me to confirm consent and detailsYour Title * Your TitleMiss.Mrs.Mr.Dr.Ms.Prof.Your First Name *Your Last Name *Your Email *Your Phone *Patient InformationPatient Title * Patient TitleMiss.Mrs.Mr.Dr.Ms.Prof.Patient Last Name *Patient First Name *Patient EmailPatient Phone *GP Surgery Name (if available at hand) (myself)Date of Birth *DD12345678910111213141516171819202122232425262728293031/MM123456789101112/YYYY2022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Exemptions (Do you pay for your prescriptions?) (myself) *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