This service is free. It will allow your pharmacist to manage your prescribed medicines and work with you and your health carers to plan the best ways to support you.

How you may benefit from registering for this extra service:

- Prompting you when your next medicine supply is due or to get a new prescription
- Dispensing your medicines in individual, easy tear-off sachets
- Making sure you don't have to make unnecessary trips to your doctor to pick up your prescriptions

By using our pharmacy prescription service, I agree to the following:

• I choose to register with Pharmacy Now for the Long Term Conditions (LTC) Pharmacy Service.
• I confirm I am residing permanently in New Zealand and am eligible to receive publicly-funded health services.
• I have read and I agree with the Health Information Privacy Statement

I understand that by registering with the Pharmacy for the Long Term Conditions Service, where possible, in order to improve the care I receive I should get my prescribed medicines and care at this pharmacy. However, I am able to have medicines dispensed at another pharmacy, for example after hours or if I am out-of-town. I also understand that I have the right to exit this service or transfer to another pharmacy at any time.

I understand that my pharmacist may need to consult with other health professionals involved, or soon to be involved in my care (which over time may extend beyond the members of my healthcare team) including where this is required for the development of a medication management plan for me, or where my pharmacist may wish to make an application for me to receive an extra level of pharmacy services.

I understand that any consent given in this form applies equally to other services I receive from my pharmacist in relation to my care.