Prescription Charges Exemption

Patients are entitled to free NHS prescriptions if they have certain medical conditions, or if they are pregnant or who have had a baby in the last 12 months. To get the free prescriptions a valid medical exemption certificate is required.

Please visit https://www.nhsbsa.nhs.uk/exemption-certificates/medical-exemption-certificates to check the medical conditions covered.

Your Details

Title

First Names

Surname

Date of BirthDD/MM/YYYY

NHS Number (if known)

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Your Contact Details

Home Address

Postcode

Telephone

Mobile

E-mail Address

Exemption Certificate

Please select which type of exemption certificate you need

Medical Condition

Maternity

Privacy Protection

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All Information submitted through secure forms is secured with a private key and is accessed over a secure connection by nominated staff. We have a strict confidentiality policy.

This information is not shared with any third party organisations.

This information is retained for up to 28 days.

I consent to my information being used for the purposes described above and wish to submit this online form to Heather Brook Health • 215 Kirkham Road, Freckleton, Lancashire, PR4 1HG.

Learn more about our Privacy Policy and Terms of Use. Should you have any concerns about sending your personal details using the web, please use one of the alternative methods offered by our organisation.