Prescription Collection and Delivery Service Registration Form

Fill in this form with your details to register for our Collection and Delivery Service. You must be the patient or have the patient's permission to submit this form. All fields are required, if you are not presented with the confirmation page after submitting this form then check the information you have provided.

Enter the characters from the picture below into the text box under neath. If you are unable to read the characters then click the blue and white arrow button next to it to get a new authorisationĀ or click on the blue and white speakerĀ button next to it to hear an audio clip instead.

Your registration form will now be submitted and authorisation sent to your Doctor for Central Pharmacy to collect your Prescriptions. By submitting this form you agree that you are the patient or that you have the patient's permission to do so. Your details will be stored securely. If there is a problem with your registration we will contact you by telephone so please ensure you have provided the correct telephone number.

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Company Registration Details

Superintendant Pharmacist: Amir Kabir (MRPharmS)

Company Registered Office:
Pharma Plus Medical LTD
Company Number: 07259684

H/O Address
7 Cecil Square