Please complete the form below to sign up for free repeat ordering service... Your name First Last Your date of birth* DD MM YYYY Your phone number*Your e-mail address* Your address* Street Address Address Line 2 City Postcode Your pharmacy*Which pharmacy would you like to dispense your prescriptions?DrylawEaster RoadGlenrothesKeltyOxgangsYour GP's name* First Last Your GP's address* Street Address Address Line 2 City Postcode Authorisation* I have read this disclaimer and authorise Dears pharmacy to collect and deliver my prescription. I authorise Dears pharmacy to order and/or collect in person, or by electronic prescription transfer, my prescription from the surgery named above. I will inform Dears pharmacy if I wish to change this arrangement. I authorise Dears pharmacy to contact me in their professional capacity, where necessary and appropriate, to inform me of any issues relating to my prescriptions and/or pharmaceutical matters by phone or any other suitable method. Dears pharmacy will not disclose your details or any other personal information obtained through this service with any third parties and will treat your information with care.