I would like to nominate LetterBoxPharmacy.com (XRP Health LTD) and give full authority to handle my acute/ repeat prescription, which includes the delivery of my medication. I understand this is an online pharmacy, therefore any essential services, such as collection of medication is prohibited, and therefore I authorise delivery of my medication.

I would like to opt-in for: (unless crossed off below)

Email marketing (inc. Goods, services, other).
Telephone Marketing
Postal Marketing
Video marketing
SMS messaging (marketing and notifying of delivery)

if am not in, please:

Post it through letter Box

Neither bring it back to the pharmacy

Deliver to my neighbour: Door number:

My details are

Name

Address

Telephone number

NHS number

Sign:

Date:

Mobile Number:

Please print and send to 20 Spelman Street, London, E1 5LQ

(XRP HEALTH LTD) Nomination Registration Form

My details are