Patient Nomination Form | Moonlight Pharmacy

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Patient Nomination Form

Moonlight Pharmacy

Please complete the below form to nominate us (Moonlight Pharmacy) to receive your prescriptions from your doctors surgery electronically.

Patients Full Name (required)

Patients Gender

Male

Female

Intermediate

Patients Date of Birth

Patients NHS Number
If you have it - This can be found on the top right hand corner of your prescriptions

Patients Email Address

Patients Address

Patients Post Code

Patients Telephone Number

Please Respond To The Following Statements

I have read and understood the information on EPS nomination and I understand what I have to do:

Agree

I confirm that that I have made my nomination of my own free will and have not been influenced or given a gift to select a particular nomination:

Agree

I hereby nominate the above named Pharmacy, to be my dispensing site for Electronic Prescriptions:

Agree

Submit

CONTACT

Wentworth Avenue
Slough
Berkshire
SL2 2DG

01753 554275

INFORMATION

Premises GPhC Number:

1106014

Superintendant:

Homa Gill (2055545)

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What do you want to do?

Visit the website home page

Visit the website page for my pharmacy

Change my pharmacy

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Please provide your email address you use to login to your account, we will then send you a password reset code.

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The following list shows all the items you have placed orders for, click on an item to see all the dates you have placed an order for the item.

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Please provide a little more information to finish setting up your account...

Which of our stores you use

Are you registered for GP online services?

The surgery you are registered with

Are you exempt from prescription charges?

A contact telephone number

Your home address

Messages

No new messages

Important: Your record may contain sensitive information. If someone is pressuring you for this information, contact your GP surgery immediately.

Your surgery does not currently allow you to place orders via GP online services. Please contact your surgery to resolve this or click here to unlink.

Online prescription ordering is not currently enabled for your branch. You can still store your items and set reminders to re-order.

You haven't set up any reminders to reorder your prescription items. Click here to setup reminders now

Your recent prescription orders

What do you want to do?

Change User

Order

Manage

Pharmacy

History

Purchases

Log Out

Please enter your login details to access your account...

Password

Keep me logged in

Help! I have forgotten my password

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To keep your password secure you will periodically need to change it. Please provide a new password to login to your account.

New Password

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If you have an NHS account you can use it to login to your account. By doing so we can automatically collect information required to connect to your GP online.

Please be aware that once you have logged in using your NHS account you must continue to login to your account this way.

You will need to give NHS login consent to share your information with us for the purposes of creating your account with us, ordering repeat prescriptions, sending your GP a message and seeing the health information your GP shares with you

You can see our full privacy policy here.

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Code

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Before logging in we would like to confirm that it really is you! To do so we will send you a code to input, please specify how you wish to receive your code.

Send via email

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What do you want to change?

My Details

My Surgery

Prescription

Reminders

My Branch

My Health

Preferences

Dependents

GP Online

Password

NHS Login Settings

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Select your local branch...

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Select this dependant as the current user

Create an account for this dependant so they can manage their account themselves

I no longer need to manage this dependants prescriptions and they will not be doing it themselves

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Add/Remove additional users who are dependant on you to place their orders for them...

Add a new dependant

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Yes

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Please provide us with a little information about your dependant...

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What is the dependants relation to you...

Parent

Child

Spouse

Family Member

Friend

Client

Other

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What do you want to change?

Your Name

Contact Info

My Address

Exempt From Prescription Charges?

NHS Number

Gender

Date of Birth

Profile Picture

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Change your address...

Country

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I cannot find my address

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Change your contact information...

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If you have set your date of birth incorrectly, you can change it here...

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Are you exempt from prescription charges?

No, I pay for my prescriptions

Yes, For age related reasons

Yes, For medical related reasons

Yes, For benefits related reasons

Yes, For prepayment related reasons

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Select the reason you are exempt from prescription charges.

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Select your gender...

Male

Female

Other

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Change your names...

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Providing your NHS number will assist us dealing with your orders. However you do not have to provide this information if you do not wish to.

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When linking to GP online services, would you like to store a copy of your prescription data so you can setup re-order reminders and we can send you updates on your order?

Yes Please

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When registering for online services with your GP you will have received a document containing the information required for the form below.

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Removing your connection to GP online services will delete all your prescription information. To re-register you will need to contact your surgery for new linkage information. This cannot be undone, are you sure you wish to continue?

Yes, unlink from GP online services

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Linking to your GP online will automatially manage your prescriptions based on information provided by your GP. If you would like to make use of this service then please contact your surgery. If you have your access codes then select 'Yes' to continue.

Yes

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What do you want to change?

My Health

Allergies

Chronic Conditions

Are you housebound?

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Please select which allergies apply to you...

Grass and tree pollen (Hay fever)

Dust mites

Animal dander, tiny flakes of skin or hair

Nuts

Certain fruits

Shellfish

Dairy products

Gluten

Insect bites and stings

Certain medicines and antibiotics

Latex (used to make some gloves and condoms)

Mould

Household chemicals (including those in detergents and hair dyes)

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Please select which conditions apply to you...

Acid Reflux

Arthritis

Asthma

Coeliac Disease

COPD

Diabetes Type 1

Diabetes Type 2

Eczema

Heart Disease

High Blood Pressure

High Cholesterol

Psoriasis

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Please let us know a little about you...

Use Metric Measurements

Please let us know a little about your health...

I am a smoker

I use a wheelchair

I am classed as vunerable by my doctor/surgery

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Please let us know if you are housebound

No, I am not housebound

Yes, I am housebound

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Please explain why you are housebound...

Other

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For security we will need you to provide your current password in order to change it.

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Change your preferences...

I would like to subscribe to updates and offers from my pharmacy

We will occasionally send you updates via email or push notification (if you have our app installed) with information from the pharmacy including changes to opening hours, changes to services, alerts for seasonal services (such as nhs flu vaccinations) public health warnings and pharmacy offers.

I would like to receive notifications on this device

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Setup the prescription items you would like to order...

Add an Item

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How many do you need?

Would you like to be reminded to reorder this?

I no longer need this

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Please search for the item you would like to add to your prescription...

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I don't need reminding

I would like reminding to order this item

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Mon

Tue

Wed

Thu

Fri

Sat

Sun

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You will need to order this now if you don't want to run out.

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Just this one time

Every 28 days

Every 56 days

Every 84 days

A different number of days

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Your recent prescription orders

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Configure your reminders to order your prescription items...

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Select the surgery you are registered with...

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Let us know who is going to be collecting your prescription for you.

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Select how you wish to receive your prescription.

Local delivery

Delivery via courier

I am housebound, I need it delivered

Free

I will collect it myself

Free

I will collect from a 24/7 collection machine

Free

Somebody else will collect for me

Free

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Please let us know of any delivery instructions you need us to know about. You can just click 'Next' if there's nothing we need to know.

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Select the items you would like to order...

Change my prescriptions and set reminders...

Select All

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Please let us know the reason for you being housebound.

Other

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If you would like to leave a note to the pharmacy then add it here. You can just click 'Next' if there's nothing we need to know.

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If you would like to leave a note to your surgery/GP then add it here. You can just click 'Next' if you do not need to add a note.

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Please provide details to pay for your prescription

Card Number

Card Expiry

Card CVC

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Please confirm your order...

Your surgery will not accept prescription requests made on your behalf by pharmacies. Please confirm that you have already requested your prescription directly from your surgery.

Your Pharmacy

Your Surgery

Your Prescription Items

To Pharmacy:

To Surgery:

Exempt From Prescription Charges

Delivery Address

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Please provide the password reset code we have emailed to you and a new password. Check your junk mail if you are unable to find the email!

Reset Code

New Password

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Check for updates from your surgery

Cancel this order

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Please provide an email and password to use to login to your account...

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Please provide a little information about yourself...

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Set your preferences...

I would like to subscribe to updates and offers from my pharmacy

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Before creating an account you must agree to our privacy policy

I agree to the privacy policy

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Your shopping orders

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Cancel this order

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Did you know?

You can quickly move between your user dashboard for ordering and managing prescriptions and our pharmacy website.

Simply swipe the screen with your finger to the side to switch.

Don't show this again

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If you are managing prescriptions on behalf of somebody else you can add them into here and place orders for them by logging into your account.

Add a dependant user

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Logging in or registering for an account with us will allow you to order your prescription, keep track of the progress of your orders, setup reminders to place your orders and much more.

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If you have an NHS login you can login to an existing account (with the same email) or register for a new account with us

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