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Date
Time---MorningAfternoonEvening
Title:Mr.Mrs.Miss.Ms.Dr.Prof.Rev.Lord.Snr.
We'll contact you within 48 hours to confirm your repeat prescription order.
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I am nominating on behalf of:MyselfSomeone else
Gender:MaleFemale
Date of Birth:
(If known - This can be found on the top right hand corner of your prescriptions)
I choose KC Pharmacy as my nominated pharmacy for EPS prescriptions and appliances
I authorise KC Pharmacy to order/collect my repeat prescriptions until further notice
KC Pharmacy will not pass on your details to anyone not involved in your clinical care. Please read our T&C's
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