NHS Prescriptions

Prescription 1

• Name on prescription
• Number of items on prescription
• Date Of Birth

  Day01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31

  Month010203040506070809101112

  Year1900190119021903190419051906190719081909191019111912191319141915191619171918191919201921192219231924192519261927192819291930193119321933193419351936193719381939194019411942194319441945194619471948194919501951195219531954195519561957195819591960196119621963196419651966196719681969197019711972197319741975197619771978197919801981198219831984198519861987198819891990199119921993199419951996199719981999200020012002200320042005200620072008200920102011

• Gender
   Male      Female     
• Is the patient pregnant or breastfeeding ?
   Yes      No     
• Does this person suffer from Heart disease?
   Yes      No      Don't know     
• Does this person suffer from Diabetes?
   Yes      No      Don't know     
• Does this person Smoke?
   Yes      No      Don't know     
• Would you like to receive information on help to reducing weight?
   Yes      No     
• Is this patient exempt from NHS prescription charges?
   Yes      No     
•  
• The patient doesn't have to pay because he/she
  --- Please Select ---is under 16 years of ageis 16, 17 or 18 and in full-time educationis 60 years of age or overhas a valid maternity exemption certificatehas a valid medical exemption certificatehas a valid prescription pre-payment certificatehas a valid War Pension exemption certificateis named on a current HC2 charges certificatewas prescribed free-of-charge contraceptivesgets Income Support or income-related Employment and Support Allowancegets income-based Jobseeker's Allowanceis entitled to, or named on, a valid NHS Tax Credit Exemption Certificatehas a partner who gets Pension Credit guarantee credit (PCGC)
• Certificate Number
• Expiry Date
   
• Name Of Person On Benefit
• National Insurance Number

I have another prescription