Delivery Eligibility Form

Please confirm that you are housebound and therefore eligible for our FREE Delivery due to one or more of the following: *

I am confined to my home due to a medical condition or disability.

I require assistance from another person or medical equipment (e.g., wheelchair, walker) to leave my home.

I have a chronic illness that makes leaving home a significant health risk.

I am under the care of a healthcare provider who has determined that travel outside the home is not feasible.

NHS Number

(you can find it on your repeat slip)

First Name *

Last Name *

Date of Birth *

Mobile Number *

(please enter a relative’s mobile number if you do not have one)

Add another patient living at same address Remove

Address Line 1 *

Address Line 2

Town *

Postcode *

Signature

Clear

NOTE: If an error occurs when you go to submit, please select the keyboard symbol and then type your name for signature. This will allow the form to submit. Thank you!

If you are human, leave this field blank.

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(18+)

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(1+)

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(Women 16-64 Yrs)

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(1-17 Years)

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(12+)

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(5+)

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(1+)

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Delivery Eligibility Form