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[% item.nhs_prescription_item.name %]

[% item.nhs_prescription_item.quantity %]

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Patient details

Please enter your first and last name exactly as it appears on your ID. This is to allow an ID verification.

First Name^*

[% errors.address.billing.firstname %]

Last Name^*

[% errors.address.billing.lastname %]

Gender^*

[% errors.address.billing.gender %]

Email address^*

[% errors.info.email %]

Date of Birth ^*

[% errors.info.dob %]

Password

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ID Check

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ID Document Type^*

[% errors.info.id_type %]

Drivers License ID Number Passport ID Number ID Card Number ^*

Where can I find this?

Example: 107185702 2 GBR 8501178 F 1601312 <<<<<<<<<<<<<< 02

Example: MORGA 753116 SM9IJ

Example: ID GBR 1234567897 <<<<<<<<<<<<<<< 7704145 F 1604117 GBR <<<<<<<<<<< 4

[% errors.info.id_number %]

The ID number you have entered appears to be incorrect. Please ensure you have entered the number exactly as it appears on your ID.

Please use the "Where can I find this" link above for help finding the ID number.

Choose a delivery option ^*

Unfortunately we are unable to post prescription medication to your country. Please see the delivery page for further information

[% errors.address.billing.firstname %]

Please enter your billing address. This is the one which is linked to your bank account and allows us to complete your ID check. You can add a different delivery address below

Country^*

Phone number^*

[% errors.info.contact_no %]

[% errors.info.phone_prefix %]

Postcode/Zip^*

[% errors.address.billing.postcode %]

Please select^*

Address Line 1^*

[% errors.address.billing.address1 %]

Address Line 2

[% errors.address.billing.address2 %]

City^*

[% errors.address.billing.city %]

[% errors.address.billing.country %]

State^*

[% errors.address.billing.state %]

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