Delivery of Prescribed Medication for Westfield Parish residents over 70s, at risk or vulnerable - Please fill in a form for each person that needs support

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* 1. Your Forename - If filling in the form for someone else please put in their details

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* 2. Your Surname

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* 3. Telephone Number

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* 4. Email Address

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* 5. Your Full Address (please include your post code)

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* 6. Are you (or the person you are filling the form in for)

Over 70

In the 'at risk' category

Considered vulnerable

Please give details why at risk or vulnerable

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* 7. Your age

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* 8. Can you please let us know if you are eligible for free prescriptions or you pay for you prescriptions by selecting one of the below. I am:

Other please briefly specify if you or your partner (including civil partner) receive, or you're under the age of 20 and the dependant of someone receiving: Income Support, income-based Jobseeker's Allowance, income-related Employment and Support Allowance, Pension Credit Guarantee Credit, Universal Credit and meet the criteria or a valid NHS tax credit exemption certificate, a valid NHS certificate for full help with health costs (HC2) or named on an NHS certificate for partial help with health costs (HC3) may also get help.

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* 9. Do you collect your medication from Westfield Surgery?

Yes

If no please let us know where you collect from.

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* 10. If you are unable to come to the door to collect your delivery is there someone in the household who can?

Not Applicable

Yes

Please give their full name and relation to you

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* 11. Do you give consent for Westfield Parish Council to store your personal details and share these with the volunteers to get you your prescribed medication or help? - Please note if you tick 'No' we will not be able to help you.

Yes