{"id":12023,"date":"2022-06-09T11:05:43","date_gmt":"2022-06-09T10:05:04","guid":{"rendered":"https:\/\/www.goringwoodcotemedicalpractice.nhs.uk\/?page_id=12023"},"modified":"2022-06-09T11:43:11","modified_gmt":"2022-06-09T10:43:11","slug":"pharmaself24-signup-form","status":"publish","type":"page","link":"https:\/\/www.goringwoodcotemedicalpractice.nhs.uk\/your-record\/keep-us-up-to-date\/pharmaself24-signup-form\/","title":{"rendered":"Pharmaself24 Signup Form"},"content":{"rendered":"\n<p>The Pharmaself24 enables you to collect your prescription <strong>24 HOURS A DAY &#8211; 365 DAYS A YEAR<\/strong>. To sign up for this service please either download the form, complete and deliver to the surgery or complete the online form below.<\/p>\n\n\n\n<div class=\"wp-block-file\"><a id=\"wp-block-file--media-e30e20d7-2789-466f-9cd8-0fd3875f7ad3\" href=\"https:\/\/www.goringwoodcotemedicalpractice.nhs.uk\/wp-content\/uploads\/2022\/06\/Pharmaself-Sign-Up-Form-Final1-1.docx\">Pharmaself24 Signup Form<\/a><a href=\"https:\/\/www.goringwoodcotemedicalpractice.nhs.uk\/wp-content\/uploads\/2022\/06\/Pharmaself-Sign-Up-Form-Final1-1.docx\" class=\"wp-block-file__button\" download aria-describedby=\"wp-block-file--media-e30e20d7-2789-466f-9cd8-0fd3875f7ad3\">Download<\/a><\/div>\n\n\n\n<hr class=\"wp-block-separator has-alpha-channel-opacity\"\/>\n\n\n<link rel='stylesheet' id='formidable-css' href='https:\/\/www.goringwoodcotemedicalpractice.nhs.uk\/wp-content\/plugins\/formidable\/css\/formidableforms.css?ver=4271614' media='all' \/>\n<div class=\"frm_forms  with_frm_style frm_style_big_text\" id=\"frm_form_49_container\" >\n<form enctype=\"multipart\/form-data\" method=\"post\" class=\"frm-show-form  frm_pro_form \" id=\"form_hnlsj6316\"  >\n<div class=\"frm_form_fields \">\n<fieldset>\n<legend class=\"frm_screen_reader\">Pharmaself24 Signup<\/legend>\r\n\r\n<div class=\"frm_fields_container\">\n<input type=\"hidden\" name=\"frm_action\" value=\"create\" \/>\n<input type=\"hidden\" name=\"form_id\" value=\"49\" \/>\n<input type=\"hidden\" name=\"frm_hide_fields_49\" id=\"frm_hide_fields_49\" value=\"\" \/>\n<input type=\"hidden\" name=\"form_key\" value=\"hnlsj6316\" \/>\n<input type=\"hidden\" name=\"item_meta[0]\" value=\"\" \/>\n<input type=\"hidden\" id=\"frm_submit_entry_49\" name=\"frm_submit_entry_49\" value=\"737667f9ef\" \/><input type=\"hidden\" name=\"_wp_http_referer\" value=\"\/wp-json\/wp\/v2\/pages\/12023\" \/><div id=\"frm_field_1448_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm_first frm_half\">\r\n    <label for=\"field_xu1tj6315\" class=\"frm_primary_label\">First Name\r\n        <span class=\"frm_required\">*<\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_xu1tj6315\" name=\"item_meta[1448]\" value=\"\"  data-reqmsg=\"First Name cannot be blank.\" aria-required=\"true\" data-invmsg=\"Text is invalid\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_1449_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm_half\">\r\n    <label for=\"field_xt7az6315\" class=\"frm_primary_label\">Last Name\r\n        <span class=\"frm_required\">*<\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_xt7az6315\" name=\"item_meta[1449]\" value=\"\"  data-reqmsg=\"Last Name cannot be blank.\" aria-required=\"true\" data-invmsg=\"Text is invalid\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_1450_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container\">\r\n    <label for=\"field_ppbxb6315\" class=\"frm_primary_label\">Email\r\n        <span class=\"frm_required\">*<\/span>\r\n    <\/label>\r\n    <input type=\"email\" id=\"field_ppbxb6315\" name=\"item_meta[1450]\" value=\"\"  data-reqmsg=\"Email cannot be blank.\" aria-required=\"true\" data-invmsg=\"Email is invalid\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_1451_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm_first frm_half\">\r\n    <label for=\"field_w1eya6315\" class=\"frm_primary_label\">Date of birth\r\n        <span class=\"frm_required\">*<\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_w1eya6315\" name=\"item_meta[1451]\" value=\"\"  data-frmmask=\"99\/99\/9999\" placeholder=\"DD\/MM\/YYYY\" data-reqmsg=\"Date of birth cannot be blank.\" aria-required=\"true\" data-invmsg=\"Text is invalid\" aria-invalid=\"false\" pattern=\"\\d\\d\\\/\\d\\d\\\/\\d\\d\\d\\d$\"   aria-describedby=\"frm_desc_field_w1eya6315\"\/>\r\n    <div class=\"frm_description\" id=\"frm_desc_field_w1eya6315\">Please use format day\/month\/year e.g. 12\/05\/1979<\/div>\r\n    \r\n<\/div>\n<div id=\"frm_field_1452_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm_half\">\r\n    <label for=\"field_spq8l4315\" class=\"frm_primary_label\">Mobile Phone Number\r\n        <span class=\"frm_required\">*<\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_spq8l4315\" name=\"item_meta[1452]\" value=\"\"  data-reqmsg=\"Mobile Phone Number cannot be blank.\" aria-required=\"true\" data-invmsg=\"Text is invalid\" aria-invalid=\"false\"   aria-describedby=\"frm_desc_field_spq8l4315\"\/>\r\n    <div class=\"frm_description\" id=\"frm_desc_field_spq8l4315\">It is ESSENTIAL that you provide your mobile number as we will be required to send you an SMS text message each time you have a prescription with your unique PIN number.<\/div>\r\n    \r\n<\/div>\n<div id=\"frm_field_1459_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container\">\n    <label for=\"field_jjv3n\" id=\"field_jjv3n_label\" class=\"frm_primary_label\">Address\n        <span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\n    <\/label>\n    <textarea name=\"item_meta[1459]\" id=\"field_jjv3n\" rows=\"5\"  data-reqmsg=\"Address cannot be blank.\" aria-required=\"true\" data-invmsg=\"Address is invalid\" aria-invalid=\"false\"  ><\/textarea>\n    \n    \n<\/div>\n<div id=\"frm_field_1458_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container vertical_radio\">\n    <div  id=\"field_c62kx_label\" class=\"frm_primary_label\">Your request for Pharmaself24 \n        <span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\n    <\/div>\n    <div class=\"frm_opt_container\" aria-labelledby=\"field_c62kx_label\" role=\"group\">\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_1458-0\"><label for=\"field_c62kx-0\"><input type=\"checkbox\" name=\"item_meta[1458][]\" id=\"field_c62kx-0\" value=\"I wish Goring and Woodcote Medical Practice to make my prescription available for collection from the Automated Prescription Collection Point\"  data-reqmsg=\"Your request for Pharmaself24  cannot be blank.\" data-invmsg=\"Your request for Pharmaself24  is invalid\" aria-invalid=\"false\"   aria-required=\"true\"  \/> I wish Goring and Woodcote Medical Practice to make my prescription available for collection from the Automated Prescription Collection Point<\/label><\/div>\n<\/div>\n    \n    \n<\/div>\n<div id=\"frm_field_1462_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container\">\n    <label for=\"field_9o3ks\" id=\"field_9o3ks_label\" class=\"frm_primary_label\">Where will you collect prescriptions from\n        <span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\n    <\/label>\n    \t\t<select name=\"item_meta[1462]\" id=\"field_9o3ks\"  data-reqmsg=\"Where will you collect prescriptions from cannot be blank.\" aria-required=\"true\" data-invmsg=\"Where will you collect prescriptions from is invalid\" aria-invalid=\"false\"  >\n\t\t<option  value=\"\" selected='selected'> <\/option><option  value=\"Goring Dispensary\">Goring Dispensary<\/option><option  value=\"Woodcote Dispensary\">Woodcote Dispensary<\/option>\t<\/select>\n\t\n    \n    \n<\/div>\n<div id=\"frm_field_1460_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container\">\n    <label for=\"field_hudh1\" id=\"field_hudh1_label\" class=\"frm_primary_label\">Your signature\n        <span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\n    <\/label>\n    <div class=\"sigPad\" id='sigPad1460' style=\"max-width:550px;\">\n\t<div class=\"sig sigWrapper\" style=\"height:150px;border-color:rgb(51,51,51);--bg-color:#ffffff;--active:#0391c6;--inactive:#dddddd;--active-text:#ffffff;--inactive-text:#ffffff;--button-margin:27px;--button-size:16px;--button-padding:8px;--button-side-margin:27.5px;--icon:20px\">\n\n\t\t<ul class=\"sigNav frm_hidden \">\n\t\t\t\t<li class=\"drawIt\">\n\t\t\t\t\t<a href=\"#\" class=\"\" title=\"Draw It\" aria-label=\"Draw It\">\n\t\t\t\t\t\t<svg  viewBox=\"0 0 22 20\" class=\"frmsvg\">\n\t<title>signature<\/title>\n\t<path d=\"M19.7 2.2A3.5 3.5 0 0 0 14 1.1L1.7 13.4a1 1 0 0 0-.3.4l-1.3 5a.9.9 0 0 0 0 .5 1 1 0 0 0 1 .6l5-1.3c.2 0 .4-.1.5-.3L18.9 6a3.5 3.5 0 0 0 .7-3.8zm-6.8 2.6L15.2 7l-8.6 8.7-2.4-2.4zm-10.7 13l1-3.3L5.4 17zM18 4.2l-.4.5L16.3 6 14 3.7l1.3-1.3A1.7 1.7 0 0 1 18 3.6l-.1.6zM9 17.9h11v1H9v-1z\"><\/path>\n\n<\/svg>\t\t\t\t\t<\/a>\n\t\t\t\t<\/li>\n\t\t\t\t<li class=\"typeIt\">\n\t\t\t\t\t<a href=\"#\" class=\"frm-active-sig-type\" title=\"Type It\" aria-label=\"Type It\">\n\t\t\t\t\t\t<svg  viewBox=\"0 0 22 20\" class=\"frmsvg\">\n\t<title>keyboard<\/title>\n\t<path d=\"M20.6 2.5H2c-1 0-1.9.8-1.9 1.9v11.2c0 1 .8 1.9 1.9 1.9h18.7c1 0 1.9-.8 1.9-1.9V4.4c0-1-.8-1.9-1.9-1.9zm.3 13.1c0 .2-.1.3-.3.3H2a.3.3 0 0 1-.3-.3V4.4c0-.2.1-.3.3-.3h18.7c.2 0 .3.1.3.3v11.2zm-14.3-5V9.4c0-.3-.2-.5-.4-.5H5c-.3 0-.5.2-.5.5v1c0 .3.2.5.5.5h1c.3 0 .5-.2.5-.5zm3.8 0V9.4c0-.3-.2-.5-.5-.5H9c-.3 0-.5.2-.5.5v1c0 .3.2.5.4.5H10c.3 0 .5-.2.5-.5zm3.7 0V9.4c0-.3-.2-.5-.4-.5h-1.1c-.3 0-.5.2-.5.5v1c0 .3.2.5.5.5h1c.3 0 .5-.2.5-.5zm3.8 0V9.4c0-.3-.2-.5-.5-.5h-1c-.3 0-.5.2-.5.5v1c0 .3.2.5.4.5h1.1c.3 0 .5-.2.5-.5zM4.8 7.2v-1c0-.3-.2-.5-.5-.5H3.2c-.3 0-.5.2-.5.4v1.1c0 .3.2.5.5.5h1.1c.3 0 .5-.2.5-.5zm3.7 0v-1c0-.3-.2-.5-.5-.5H7c-.3 0-.5.2-.5.4v1.1c0 .3.2.5.5.5h1c.3 0 .5-.2.5-.5zm3.8 0v-1c0-.3-.2-.5-.5-.5h-1.1c-.3 0-.5.2-.5.4v1.1c0 .3.2.5.5.5h1.1c.3 0 .5-.2.5-.5zm3.7 0v-1c0-.3-.2-.5-.5-.5h-1c-.3 0-.5.2-.5.4v1.1c0 .3.2.5.5.5h1c.3 0 .5-.2.5-.5zm3.8 0v-1c0-.3-.2-.5-.5-.5h-1.1c-.3 0-.5.2-.5.4v1.1c0 .3.2.5.5.5h1.1c.3 0 .5-.2.5-.5zm-2 6.2V13c0-.3-.2-.5-.6-.5h-12c-.3 0-.6.2-.6.5v.6c0 .3.3.5.7.5h12c.3 0 .6-.2.6-.5z\"><\/path>\n<\/svg>\t\t\t\t\t<\/a>\n\t\t\t\t<\/li>\n\t\t<\/ul>\n\n\t\t<span class=\"frm-typed-drawline\"><\/span>\n\n\t\t<div class=\"typed\">\n\t\t\t<input type=\"text\" name=\"item_meta[1460][typed]\" class=\"name\" id=\"field_hudh1\" autocomplete=\"off\" value=\"\"  style=\"width:550px\" maxlength=\"150\" data-reqmsg=\"Your signature cannot be blank.\" aria-required=\"true\" class=\"auto_width\" aria-invalid=\"false\"   \/>\n\t\t<\/div>\n\n\t\t<canvas class=\"pad\" data-fieldid=\"1460\" data-fieldname=\"item_meta[1460]\" width=\"546\" height=\"150\"><\/canvas>\n\t\t<div class=\"clearButton\"><a href=\"#clear\">Clear<\/a><\/div>\n\n\t\t<input type=\"hidden\" name=\"item_meta[1460][output]\" class=\"output\" value=\"\" \/>\n\t<\/div>\n<\/div>\n\n    <div class=\"frm_description\" id=\"frm_desc_field_hudh1\">Please type your name to indicate your signature<\/div>\n    \n<\/div>\n<input type=\"hidden\" name=\"item_meta[1461]\" id=\"field_1mbk4\" value=\"30\/04\/2024\"  data-frmval=\"30\/04\/2024\"   \/>\n<div id=\"frm_field_1454_container\" class=\"frm_form_field frm_section_heading form-field \">\r\n<h3 class=\"frm_pos_top frm_section_spacing\">Privacy Policy<\/h3>\r\n\r\n\r\n<div id=\"frm_field_1455_container\" class=\"frm_form_field  frm_html_container form-field\">This form collects your name, date of birth, email, other personal information and medical details. This is to confirm you are registered with the practice, to allow the practice team to contact you and also to update your medical records held by the practice and our partners in the NHS. Please read our <a href=\"https:\/\/www.goringwoodcotemedicalpractice.nhs.uk\/about-us\/practice-policies\/patient-record\/how-we-use-your-data\/privacy-policy\/\" target=\"_blank\">Privacy Policy<\/a> to discover how we protect and manage your submitted data.<\/div>\n<div id=\"frm_field_1456_container\" class=\"frm_form_field form-field  frm_required_field frm_inline_container vertical_radio\">\r\n    <label for=\"field_4oeoa5\" class=\"frm_primary_label\"> \r\n        <span class=\"frm_required\">*<\/span>\r\n    <\/label>\r\n    <div class=\"frm_opt_container\">\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_1456-1454-0\"><label for=\"field_4oeoa5-0\"><input type=\"checkbox\" name=\"item_meta[1456][]\" id=\"field_4oeoa5-0\" value=\"I consent to the practice collecting and storing my data from this form.\"  data-sectionid=\"1454\" data-reqmsg=\"We need your consent to proceed. Please tick the box to consent.\" data-invmsg=\"  is invalid\" aria-invalid=\"false\"   aria-required=\"true\"  \/> I consent to the practice collecting and storing my data from this form.<\/label><\/div>\n<\/div>\r\n    \r\n    \r\n<\/div>\n<\/div>\n\t<input type=\"hidden\" name=\"item_key\" value=\"\" \/>\n\t\t\t\t<div class=\"frm__654e4ddcbd5cd\">\n\t\t\t\t<label for=\"frm_email_49\" >\n\t\t\t\t\tIf you are human, leave this field blank.\t\t\t\t<\/label>\n\t\t\t\t<input  id=\"frm_email_49\" type=\"text\" class=\"frm_verify\" name=\"frm__654e4ddcbd5cd\" value=\"\" autocomplete=\"false\"  \/>\n\t\t\t<\/div>\n\t\t<input name=\"frm_state\" type=\"hidden\" value=\"imo+qVs8NS2uaFZQAgJVedOfh8etL8u58DnR2MdktfDY34n6uINE8hKCnGU+FpQc\" \/><div class=\"frm_submit\">\r\n\r\n<button class=\"frm_button_submit frm_final_submit\" type=\"submit\"   formnovalidate=\"formnovalidate\">Send<\/button>\r\n\r\n<\/div><\/div>\n<\/fieldset>\n<\/div>\n<\/form>\n<\/div>\n","protected":false},"excerpt":{"rendered":"<p>The Pharmaself24 enables you to collect your prescription 24 HOURS A DAY &#8211; 365 DAYS A YEAR. To sign up for this service please either download the form, complete and deliver to the surgery or complete the online form below.<\/p>\n","protected":false},"author":6577921,"featured_media":0,"parent":94,"menu_order":3,"comment_status":"closed","ping_status":"closed","template":"","meta":{"_acf_changed":false,"_coblocks_attr":"","_coblocks_dimensions":"","_coblocks_responsive_height":"","_coblocks_accordion_ie_support":"","_uag_custom_page_level_css":"","footnotes":"","_links_to":"","_links_to_target":""},"acf":[],"uagb_featured_image_src":{"full":false,"thumbnail":false,"medium":false,"medium_large":false,"large":false,"1536x1536":false,"2048x2048":false,"mailpoet_newsletter_max":false},"uagb_author_info":{"display_name":"Editor","author_link":"https:\/\/www.goringwoodcotemedicalpractice.nhs.uk\/author\/gary-genpra\/"},"uagb_comment_info":0,"uagb_excerpt":"The Pharmaself24 enables you to collect your prescription 24 HOURS A DAY &#8211; 365 DAYS A YEAR. To sign up for this service please either download the form, complete and deliver to the surgery or complete the online form below.","publishpress_future_action":{"enabled":false,"date":"2024-05-07 03:43:18","action":"change-status","newStatus":"draft","terms":[],"taxonomy":""},"_links":{"self":[{"href":"https:\/\/www.goringwoodcotemedicalpractice.nhs.uk\/wp-json\/wp\/v2\/pages\/12023"}],"collection":[{"href":"https:\/\/www.goringwoodcotemedicalpractice.nhs.uk\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/www.goringwoodcotemedicalpractice.nhs.uk\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/www.goringwoodcotemedicalpractice.nhs.uk\/wp-json\/wp\/v2\/users\/6577921"}],"replies":[{"embeddable":true,"href":"https:\/\/www.goringwoodcotemedicalpractice.nhs.uk\/wp-json\/wp\/v2\/comments?post=12023"}],"version-history":[{"count":2,"href":"https:\/\/www.goringwoodcotemedicalpractice.nhs.uk\/wp-json\/wp\/v2\/pages\/12023\/revisions"}],"predecessor-version":[{"id":12031,"href":"https:\/\/www.goringwoodcotemedicalpractice.nhs.uk\/wp-json\/wp\/v2\/pages\/12023\/revisions\/12031"}],"up":[{"embeddable":true,"href":"https:\/\/www.goringwoodcotemedicalpractice.nhs.uk\/wp-json\/wp\/v2\/pages\/94"}],"wp:attachment":[{"href":"https:\/\/www.goringwoodcotemedicalpractice.nhs.uk\/wp-json\/wp\/v2\/media?parent=12023"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}