Home About Us Services Free Flu Vaccination Service Stop Smoking Service Obesity Diabetes Screening Coronary Heart Disease Private Prescriptions Place An Order Bookings Contact Us chel pharmacy ETP Nomination Form Full Name Date of Birth Full Address Telephone Mobile Email Doctors Name Surgery Name Surgery Address Please confirm: Please confirm: I would like Chel Pharmacy to keep my repeat slip to order my medication on contact from myself or representative I would like Chel Pharmacy to collect my prescription from my surgery, either in person or by means of electronic transfer. By ticking these boxes, I confirm that I will inform Chel Pharmacy if I wish to make changes to these arrangements. Are you the: Are you the: Patient Authorised Representative Representatives Full Name Relationship to patient Submit