Please fill in as much as you can.
First Name (required)
Last Name (required)
Date of birth (required)
Your Email (required)
Phone or Mobile
Street Address (required)
Are you exempt from prescription charges? please state or you must pay fees (unless if under 16 over 60 which is an automatic exemption)
The Small Print about the personal information you provide above (but not in print so small that we don’t want you to read it). To provide you with this service it is required that we comply with our NHS Dispensing Appliance Contract terms and conditions which states that we need to collect and share this information from time to time with your GP and other NHS healthcare professionals involved in your care. This will be done sensitively and handled in accordance to NHS Information Governance and the Data Protection Act 1998 and the key principals of Caldicott; in protecting the security and confidentiality of personal information. While we are serving you, your personal information may be disclosed to specific NHS medical personnel in the unlikely case for reporting of an adverse event, a complaint and/or the necessity to change or re-supply specific medical appliances; under these circumstances MSC will need to share identifiable data and information to comply with mandatory reporting obligations regarding patient safety as legislated by the appropriate government regulatory
authorities. Should this ever be necessary we will inform you first. The delivery partners we use will only receive your address and any other information you have authorised us to pass on such as telephone/mobile number and special delivery instructions You can revoke your consent at any time verbally to take immediate effect but ideally, we would also ask you to follow that up in writing as soon as possible.