Lunts Pharmacies will collect your prescription, dispense it and have your medication available for collection from the pharmacy of your choice - our "Self Collect" service. Alternatively you can have your medication delivered to your home address - our "Home Delivery" service   * Any prescription collection requests entered after 11.30am will be collected the next working day *
Full Name
Address
Postcode
Telephone Number (In case we need to contact you)
	I pay for my prescriptions
	I don't pay because ...	-- Choose Reason for Exemption -- is under 16 years of ageis 16, 17 or 18 and in full-time educationis 60 years of age or overhas a valid maternity exemption certificatehas a valid medicalexemption certificatehas a valid prescription pre-payment certificatehas a valid War Pension exemption certificateis named on a current HC2 charges certificatewas prescribed free-of-charge contraceptivesgets Income Support (IS)gets income based Jobseeker's Allowance (JSA (1B))is entitled to, or named on, a valid NHS Tax Credit Exemption Cedrtificatehas a partner who gets Pension Credit guarantee credit (PCGC)
	(Penalty charges may be applied if you make a wrongful claim, If you are unsure please do not submit a request by the internet)
Which of our pharmacies do you usually use?	-- Choose Pharmacy -- Lunts Hereford RoadLunts PontesburyLunts Roushill
Surgery/Practice	-- Choose Surgery -- Albert Road Medical CentreBeeches Medical PracticeBelvidere Medical PracticeClaremont Bank SurgeryMarden SurgeryMarysville Medical PracticeMount Pleasant Medical CentreMytton Oak SurgeryPontesbury Medical CentreRadbrook Green SurgeryRiverside Medical PracticeSouth Hermitage Surgery
Date Prescription Ready	-- Choose Date -- Wed Mar 10, 2010 Thu Mar 11, 2010 Fri Mar 12, 2010 Mon Mar 15, 2010 Tue Mar 16, 2010 Wed Mar 17, 2010 Thu Mar 18, 2010 Fri Mar 19, 2010 Mon Mar 22, 2010 Tue Mar 23, 2010 Wed Mar 24, 2010 Thu Mar 25, 2010 Fri Mar 26, 2010 Mon Mar 29, 2010 Tue Mar 30, 2010 Wed Mar 31, 2010 Thu Apr 1, 2010 Fri Apr 2, 2010 Mon Apr 5, 2010 Tue Apr 6, 2010 Wed Apr 7, 2010 Thu Apr 8, 2010 Fri Apr 9, 2010 Mon Apr 12, 2010 Tue Apr 13, 2010 Wed Apr 14, 2010 Thu Apr 15, 2010 Fri Apr 16, 2010 Mon Apr 19, 2010 Tue Apr 20, 2010 Wed Apr 21, 2010 Thu Apr 22, 2010 Fri Apr 23, 2010 Mon Apr 26, 2010 Tue Apr 27, 2010 Wed Apr 28, 2010 Thu Apr 29, 2010 Fri Apr 30, 2010 Mon May 3, 2010 Tue May 4, 2010 Wed May 5, 2010 Thu May 6, 2010 Fri May 7, 2010 Mon May 10, 2010 Tue May 11, 2010 Wed May 12, 2010 Thu May 13, 2010 Fri May 14, 2010 Mon May 17, 2010 Tue May 18, 2010 Wed May 19, 2010 Thu May 20, 2010 Fri May 21, 2010 Mon May 24, 2010 Tue May 25, 2010 Wed May 26, 2010 Thu May 27, 2010 Fri May 28, 2010 Mon May 31, 2010 Tue Jun 1, 2010 Wed Jun 2, 2010 Thu Jun 3, 2010 Fri Jun 4, 2010 Mon Jun 7, 2010 Tue Jun 8, 2010
Self Collect	I will collect my own medication from my chosen Lunts Pharmacy. Please allow us one day to prepare your prescription after we have collected it.
	OR
Home Delivery	Please collect my prescription and deliver my medicine to the above address. Please allow two days for delivery. Most deliveries are made between 1pm and 8pm and will need to be signed for.
Lunts Pharmacies are registered under the terms of the Data Protection Act. None of the information collected will be passed on to a third party.