Please fill out the following form in order to participate in our activity.
I am the patient named above and consent for this nomination/have consent from the named above for request of this nomination.
I have read/been given the EPS Nomination information.
I understand what EPS nomination is and involves.
I would like to nominate Epicare Health Pharmacy as my nominated pharmacy for dispensing my prescriptions issued by NHS EPS.
Thanks for submitting!