EPS Nomination

Full Name*

Phone Number*

Email Address*

Date of Birth*

Address Line 1*

Address Line 2

Address Line 3

Postcode*

GP Details*

Are you exempt from paying?*
YesNo

Upload proof of exemption (jpg, png or pdf)

Collection or delivery?
We offer prescription delivery for eligible patients, please select your option below and we'll be in touch.
Collect in pharmacyDelivery

By ticking this box you are consenting to your future prescriptions being sent electronically to Sama Pharmacy. We will then dispense your prescriptions and deliver them to you. You can change this nomination at any time.

I accept