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Preferred Pharmacy
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Additional Contact Information
First Name
*
Last Name
*
Date of Birth
*
Email
*
Enter Email
Phone Number
*
Which Pharmacy would you like to collect your prescriptions from?
Partick Pharmacy
Park Road Pharmacy
Reach Pharmacy
Boots Byres Road
Boots Great Western Road
Boots Partick
Privacy Policy
This form collects your name, date of birth, email, other personal information and medical details. This is to confirm you are registered with the practice, to allow the practice team to contact you and also to update your medical records held by the practice and our partners in the NHS. Please read our
Privacy Policy
to discover how we protect and manage your submitted data.
*
I consent to the practice collecting and storing my data from this form.
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