{"id":1169,"date":"2025-02-11T10:41:19","date_gmt":"2025-02-11T10:41:19","guid":{"rendered":"https:\/\/dev.devbunch.com\/wellfield\/?page_id=1169"},"modified":"2025-02-12T10:52:03","modified_gmt":"2025-02-12T10:52:03","slug":"prescription","status":"publish","type":"page","link":"https:\/\/dev.devbunch.com\/wellfield\/prescription\/","title":{"rendered":"Prescription"},"content":{"rendered":"\t\t<div data-elementor-type=\"wp-page\" data-elementor-id=\"1169\" class=\"elementor elementor-1169\">\n\t\t\t\t<div class=\"elementor-element elementor-element-9558b1d e-flex e-con-boxed e-con e-parent\" data-id=\"9558b1d\" data-element_type=\"container\">\n\t\t\t\t\t<div class=\"e-con-inner\">\n\t\t\t\t<div class=\"elementor-element elementor-element-241b3ce elementor-widget elementor-widget-elementskit-contact-form7\" data-id=\"241b3ce\" data-element_type=\"widget\" data-widget_type=\"elementskit-contact-form7.default\">\n\t\t\t\t\t<div class=\"ekit-wid-con\" ><div class=\"ekit-form\">\n<div class=\"wpcf7 no-js\" id=\"wpcf7-f1168-p1169-o1\" lang=\"en-US\" dir=\"ltr\" data-wpcf7-id=\"1168\">\n<div class=\"screen-reader-response\"><p role=\"status\" aria-live=\"polite\" aria-atomic=\"true\"><\/p> <ul><\/ul><\/div>\n<form action=\"\/wellfield\/prescription\/#wpcf7-f1168-p1169-o1\" method=\"post\" class=\"wpcf7-form init\" aria-label=\"Contact form\" novalidate=\"novalidate\" data-status=\"init\">\n<div style=\"display: none;\">\n<input type=\"hidden\" name=\"_wpcf7\" value=\"1168\" \/>\n<input type=\"hidden\" name=\"_wpcf7_version\" value=\"6.0.6\" \/>\n<input type=\"hidden\" name=\"_wpcf7_locale\" value=\"en_US\" \/>\n<input type=\"hidden\" name=\"_wpcf7_unit_tag\" value=\"wpcf7-f1168-p1169-o1\" \/>\n<input type=\"hidden\" name=\"_wpcf7_container_post\" value=\"1169\" \/>\n<input type=\"hidden\" name=\"_wpcf7_posted_data_hash\" value=\"\" \/>\n<\/div>\n<div class=\"cf7-custom-form\">\n\t<div class=\"cf7-row\">\n <!-- Left Column -->\n\t\t<div class=\"cf7-column\">\n\t\t\t<h4>Part One:<br \/>\nYour details - as registered at your local GP\n\t\t\t<\/h4>\n\t\t<hr class=\"border-bottom border-success\" \/>\n\t\t\t<p class=\"form-group d-flex\"><label>Title<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"title\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"title\" value=\"Mr\" \/><span class=\"wpcf7-list-item-label\">Mr<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"radio\" name=\"title\" value=\"Mrs\" \/><span class=\"wpcf7-list-item-label\">Mrs<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"radio\" name=\"title\" value=\"Ms\" \/><span class=\"wpcf7-list-item-label\">Ms<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"title\" value=\"Other\" \/><span class=\"wpcf7-list-item-label\">Other<\/span><\/span><\/span><\/span>\n\t\t\t<\/p>\n\t\t\t<p class=\"form-group fg d-flex\"><label>Full name<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"full-name\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"\" value=\"\" type=\"text\" name=\"full-name\" \/><\/span>\n\t\t\t<\/p>\n\t\t\t<p class=\"form-group fg d-flex\"><label>Address<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"address\"><textarea cols=\"40\" rows=\"10\" maxlength=\"2000\" class=\"wpcf7-form-control wpcf7-textarea\" aria-invalid=\"false\" placeholder=\"\" name=\"address\"><\/textarea><\/span>\n\t\t\t<\/p>\n\t\t\t<p class=\"form-group fg d-flex dob\"><label>Date of Birth<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"dob\"><input class=\"wpcf7-form-control wpcf7-date wpcf7-validates-as-required wpcf7-validates-as-date\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"date\" name=\"dob\" \/><\/span>\n\t\t\t<\/p>\n\t\t\t<p class=\"form-group fg d-flex\"><label>Mobile<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"mobile\"><input class=\"wpcf7-form-control wpcf7-number wpcf7-validates-as-required wpcf7-validates-as-number\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"\" value=\"\" type=\"number\" name=\"mobile\" \/><\/span>\n\t\t\t<\/p>\n\t\t\t<h4>Part Two:<br \/>\nReceiving your prescription\n\t\t\t<\/h4>\n\t\t<hr class=\"border-bottom border-success\" \/>\n\t\t\t<p><br \/>\nPlease specify whether you require delivery or wish to collect your prescription:\n\t\t\t<\/p>\n\t\t\t<p class=\"ptwo\"><span class=\"wpcf7-form-control-wrap\" data-name=\"prescription-choice\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"prescription-choice\" value=\"Collection\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">Collection<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"prescription-choice\" value=\"Delivery (currently unavailable)\" \/><span class=\"wpcf7-list-item-label\">Delivery (currently unavailable)<\/span><\/span><\/span><\/span><br \/>\n<label>Your prescriptions will be ready to collect from your nomitated pharmacy in Part Three of this<br \/>\nform.<\/label>\n\t\t\t<\/p>\n\t\t<\/div>\n\n <!-- Right Column -->\n\t\t<div class=\"cf7-column\">\n\t\t\t<h4>Part Three:<br \/>\nCurrent services\n\t\t\t<\/h4>\n\t\t<hr class=\"border-bottom border-success\" \/>\n\t\t\t<p class=\"fg\"><label>Please specify the pharmacy you would like to dispense your prescriptions:<\/label><br \/>\n<select name=\"pharmacy\"><option value='2299'>Ashbourne Pharmacy<\/option><option value='1348'>Banstead Pharmacy<\/option><option value='1322'>Barlow Pharmacy<\/option><option value='1349'>Barming Pharmacy<\/option><option value='1333'>Battle Hill Pharmacy<\/option><option value='1335'>Berwick- Well Close Pharmacy<\/option><option value='2324'>Biggleswade Pharmacy<\/option><option value='2289'>Blaby Pharmacy<\/option><option value='1318'>Bloomfield Pharmacy<\/option><option value='1340'>Bovey Tracey Fountain court<\/option><option value='2325'>Boxalls Pharmacy<\/option><option value='1341'>Brannam Pharmacy<\/option><option value='1336'>Brockwell Pharmacy<\/option><option value='1332'>Buxton Pharmacy<\/option><option value='2524'>Chain Lane Pharmacy<\/option><option value='2300'>Chapel Street Pharmacy<\/option><option value='1338'>Clive Parade Pharmacy<\/option><option value='2303'>Clowne Pharmacy<\/option><option value='2327'>Coulby Pharmacy<\/option><option value='2301'>Crich Pharmacy<\/option><option value='1327'>Delamere Pharmacy<\/option><option value='1337'>Dudley Pharmacy<\/option><option value='2302'>Duffield Pharmacy<\/option><option value='2292'>Fountain Street Pharmacy<\/option><option value='1330'>Gorton Pharmacy<\/option><option value='1350'>Grove Green Pharmacy<\/option><option value='2304'>Hasland Pharmacy<\/option><option value='1325'>Healey Pharmacy<\/option><option value='1352'>Hollington Pharmacy<\/option><option value='2323'>Holme Hall Pharmacy<\/option><option value='1324'>Legh Street Pharmacy<\/option><option value='1346'>Longhill Pharmacy<\/option><option value='2328'>Middle Warren Pharmacy<\/option><option value='1321'>Middleton Pharmacy<\/option><option value='2293'>Moorlands Pharmacy<\/option><option value='1343'>Mount Pharmacy<\/option><option value='1326'>Mount Road Pharmacy<\/option><option value='2295'>Nabbs Pharmacy<\/option><option value='1347'>Porterbrook Pharmacy<\/option><option value='1323'>Portway Pharmacy<\/option><option value='1331'>Rainhill Pharmacy<\/option><option value='2296'>Russell Pharmacy<\/option><option value='2297'>Sherwood Pharmacy<\/option><option value='1342'>Skipton Pharmacy<\/option><option value='2326'>Springfield Pharmacy<\/option><option value='2298'>Torkard Pharmacy<\/option><option value='1334'>Tweedmouth Pharmacy<\/option><option value='2504'>Vernon St Pharmacy<\/option><option value='2290'>Villers Pharmacy<\/option><option value='1320'>Wellfield Pharmacy<\/option><option value='1345'>Wellington House Pharmacy<\/option><option value='2294'>West Street Pharmacy<\/option><option value='2291'>Whitwick Road Pharmacy<\/option><option value='2329'>Winterbottom Pharmacy<\/option><option value='1351'>Witham Pharmacy<\/option><\/select>\n\t\t\t<\/p>\n\t\t\t<p class=\"fg\"><label>Please specify which surgery you are registered with:<\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"surgery\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" placeholder=\"\" value=\"\" type=\"text\" name=\"surgery\" \/><\/span>\n\t\t\t<\/p>\n\t\t\t<h4>Part Four:<br \/>\nPayment & Exemption\n\t\t\t<\/h4>\n\t\t<hr class=\"border-bottom border-success\" \/>\n\t\t\t<p class=\"fg\"><br \/>\n<label>Please specify whether you pay for your prescriptions or if you have an exemption:<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"payment-option\"><select class=\"wpcf7-form-control wpcf7-select\" aria-invalid=\"false\" name=\"payment-option\"><option value=\"--- Please Select ---\">--- Please Select ---<\/option><option value=\"No Exemption\">No Exemption<\/option><option value=\"16, 17 or 18 and in full-time education\">16, 17 or 18 and in full-time education<\/option><option value=\"60 years of age or over\">60 years of age or over<\/option><option value=\"Valid maternity exemption certificate\">Valid maternity exemption certificate<\/option><option value=\"Valid medical exemption certificate\">Valid medical exemption certificate<\/option><option value=\"Valid prescription pre-payment certificate\">Valid prescription pre-payment certificate<\/option><option value=\"Valid War Pension exemption certificate\">Valid War Pension exemption certificate<\/option><option value=\"Named on a current HC2 charges certificate\">Named on a current HC2 charges certificate<\/option><option value=\"Prescribed free-of-charge contraceptives\">Prescribed free-of-charge contraceptives<\/option><option value=\"Income support or income-related Employment and Support Allowance\">Income support or income-related Employment and Support Allowance<\/option><option value=\"Income-based Jobseeker\u2019s Allowance\">Income-based Jobseeker\u2019s Allowance<\/option><option value=\"Entitled to, named on, a valid NHS Tax Credit Exemption Certificate\">Entitled to, named on, a valid NHS Tax Credit Exemption Certificate<\/option><option value=\"Partner gets Pension Credit guarantee credit (PCGC)\">Partner gets Pension Credit guarantee credit (PCGC)<\/option><option value=\"Under 16 years of age\">Under 16 years of age<\/option><\/select><\/span>\n\t\t\t<\/p>\n\t\t\t<h4>Part Five:<br \/>\nRegister to use this service\n\t\t\t<\/h4>\n\t\t<hr class=\"border-bottom border-success\" \/>\n\t\t\t<p class=\"terms\"><br \/>\nI am the patient\/patient\u2019s representative and would like to register to use the selected pharmacy in<br \/>\nthis form for the NHS Prescription Service.<br \/>\nI understand EPS nomination and nominate Allied Pharmacies to dispense my prescriptions.<br \/>\nBy signing this form, I give permission for information about my repeat medicines to be sent between my<br \/>\ndoctor and the selected pharmacy.\n\t\t\t<\/p>\n\t\t\t<p class=\"terms\"><br \/>\nIf I have stated I am exempt from payment, I confirm I am properly entitled to exemption and that if my<br \/>\nentitlement changes, I will tell you immediately on 0127 088 2049.\n\t\t\t<\/p>\n\t\t\t<p class=\"form-group fg d-flex\"><label>Signature<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"signature\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" placeholder=\"\" value=\"\" type=\"text\" name=\"signature\" \/><\/span>\n\t\t\t<\/p>\n\t\t\t<p class=\"form-group fg d-flex\"><label>Date<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"form-date\"><input class=\"wpcf7-form-control wpcf7-date wpcf7-validates-as-date\" aria-invalid=\"false\" value=\"\" type=\"date\" name=\"form-date\" \/><\/span>\n\t\t\t<\/p>\n\t\t\t<p class=\"submit-button\"><input class=\"wpcf7-form-control wpcf7-submit has-spinner\" type=\"submit\" value=\"Save and send details\" \/>\n\t\t\t<\/p>\n\t\t<\/div>\n\t<\/div>\n<\/div><div class=\"wpcf7-response-output\" aria-hidden=\"true\"><\/div>\n<\/form>\n<\/div>\n<\/div><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t","protected":false},"excerpt":{"rendered":"<p>Part One: Your details &#8211; as registered at your local GP Title MrMrsMsOther Full name Address Date of Birth Mobile Part Two: Receiving your prescription Please specify whether you require delivery or wish to collect your prescription: CollectionDelivery (currently unavailable) Your prescriptions will be ready to collect from your nomitated pharmacy in Part Three of [&hellip;]<\/p>\n","protected":false},"author":1,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"_acf_changed":false,"footnotes":""},"class_list":["post-1169","page","type-page","status-publish","hentry"],"acf":[],"_links":{"self":[{"href":"https:\/\/dev.devbunch.com\/wellfield\/wp-json\/wp\/v2\/pages\/1169","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/dev.devbunch.com\/wellfield\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/dev.devbunch.com\/wellfield\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/dev.devbunch.com\/wellfield\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/dev.devbunch.com\/wellfield\/wp-json\/wp\/v2\/comments?post=1169"}],"version-history":[{"count":144,"href":"https:\/\/dev.devbunch.com\/wellfield\/wp-json\/wp\/v2\/pages\/1169\/revisions"}],"predecessor-version":[{"id":1315,"href":"https:\/\/dev.devbunch.com\/wellfield\/wp-json\/wp\/v2\/pages\/1169\/revisions\/1315"}],"wp:attachment":[{"href":"https:\/\/dev.devbunch.com\/wellfield\/wp-json\/wp\/v2\/media?parent=1169"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}