Sign Up

Title

Full Name

Phone (Home)

Phone (Mobile)

Email Address

Date of Birth

Address Line 1

Address Line 2

Address Line 3

Postcode

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

I accept

I would like to sign up for 24/7 collection.