Mount Eagles Pharmacy

Patient login/sign up form

With the current Coronavirus pandemic and associated social distancing and isolation it is vitally important that the pharmacy has your contact details to be able to phone , e-mail or otherwise get in touch with you remotely to discuss any issues with your prescription medication. Please fill in this form online, request a copy to be e-mailed to you or obtain a hard copy from the pharmacy.

Patient Date of Birth

I wish to nominate Mount Eagles Pharmacy to receive my prescriptions from my GP surgery named above.

By submitting the declaration you confirm that you are or are authorised to act on behalf of the patient and consent to your/their information being used as stated on this form.
I hereby authorise Mount Eagles Pharmacy to collect either in person or by means of electronic transfer, my prescriptions from the surgery shown above on my behalf. I will inform you if I wish to make any changes to this agreement.
I agree to give Mount Eagles Pharmacy authority to contact me and/or my surgery by post, phone or electronic means to verify prescription items or resolve medication queries.
To offer this service Mount Eagles Pharmacy will hold the information you provide on this form on computer and otherwise for administration, maintenance and governance purposes while adhering to all GDPR guidlines. I understand that I have the right to remove or cancel my nomination at any time.

I or my representative will collect my prescription from Mount Eagles Pharmacy in person.
I am housebound, in a high risk group (elderly or underlying health conditions etc.) or in isolation and have no representative to collect my medicine and wish to have my medicines delivered..

Please tick collection by
you the patient patient representative

We will contact you by e-mail, text or phone call to arrange collection. Please do not come to Drive Thru collection without having received confirmation that your prescription is ready.

If you have run out of medicines or have not received notification please call the pharmacy on 028 90 601500 and speak with a member of staff.

We will contact you by e-mail, text or telephone to confirm that your prescription has been collected from your GP surgery and is ready for delivery.

Due the coronavirus pandemic our delivery driver will leave your medicines at your door, knock the door or window and move away. He will leave if you acknowledge through a window or from a distance that you have seen him. If the delivery driver has not seen you at the door/window he may give you a phone to confirm that he is delivering your medicines.

If you are have run out of medicines or have not received notification, please call the pharmacy on 028 90 601500 and speak with a member of staff.