*If any of your details change, please contact Olive Pharmacy immediately.
If stated exempt from payment, I declare that the patient does not have to pay NHS prescription charges, is properly entitled to
exemption and that the information is true and complete. I further declare that should the entitlement change, I will inform Olive Pharmacy immediately, and I understand that if I do not do so appropriate action may be taken.
WARNING! False information may lead to legal action.
We will not sell your information to anyone, for any reason.
I give my permission to Olive Pharmacy to order and receive prescriptions (paper or electric) from my doctor's surgery and to verify my required prescription items. I will contact Olive Pharmacy if you want any arrangements changed. I give permission to Olive Pharmacy to hold the information provided in this form.