Step 1 of 2 50% This application is for care leavers who are NOT already eligible for free NHS Prescriptions(Required) I agree Your Personal DetailsName(Required) First Last Date of birth(Required) MM slash DD slash YYYY NHS numberAddress(Required) Street Address Address Line 2 City Postal code Phone numberEmail(Required) Name of you GP(Required) Name of you GP practice(Required) GP practice address Street Address Address Line 2 City Postal code Details of Personal Advisor / Leaving Care WorkerName of Personal Advisor / Leaving Care Worker(Required)Personal Advisor / Leaving Care Worker Email AddressPersonal Advisor / Leaving Care Worker Telephone Number (if known)Leaving Care TeamDetails of requestWhat is your application for?(Required) One-off prescription 3 months – Pre-Payment Certificate 12 months – Pre-Payment Certificate Have you already collected and paid for your prescription?(Required) Yes No I don’t currently have a prescription to be filled but I am requesting a pre-payment certificate ahead of my next prescription Other supporting informationYou are not required to answer the questions below to receive the support you need. However, this information would be useful for our evaluation of this scheme.Are you intending to use a pre-payment prescription to purchase items for health concerns listed above which can be purchased in your local pharmacy? Yes No If yes, please tell us which health concerns you are looking to seek support forDo you have a long-term health condition or disability? Yes No If yes, please give more details on your condition or disabilityDo you have an ongoing health need that will require prescriptions for more than 3 months? Yes No If yes, please give more details on your health needsCAPTCHA