Sign Up

Complete this form to sign-up

Please complete this form to sign up/nominate Chippenham Pharmacy as your pharmacy of choice, ensuring that all the information is entered accurately. By filling in this form you are asking your doctor to send all your electronic prescriptions to our pharmacy. You can change this nomination at any time.

Take a look at our privacy policy to understand how we use and protect your data.


    If you would like your prescription to be delivered to another address, please put the details below. (optional)

    By ticking this box you are consenting to being added to our database and your future prescriptions being
    sent electronically to Chippenham Pharmacy & Health Clinic. We will then dispense your prescriptions and
    deliver them to you. You can change this nomination at any time.