Pharmacy Nomination Form Who are you completing this form for?For example, on behalf of a child or dependent. Yourself Someone else Name First Last Date of birth DD slash MM slash YYYY PostcodeThe one used to register with your GP. ZIP / Postal Code Phone numberEmail Enter Email Confirm Email My chosen pharmacy is: Superdrug Pharmacy, 55-59 Broad Street, RG1 2AF Boots, 47-48 Broad Street, RG1 2AE Saood Pharmacy, 104A Oxford Road, RG1 7LL Boots, 25 Town Mall Walk, RG1 2AH Other