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I .............................................................................(person's full name)

........................................................................................................

...........................................................................................(address)

The following:

............................................................................(description of goods)

........................................................................................................

Declare that:

I am chronically sick or have a disabling condition by reason of (give a full and specific description of your condition)

.......................................................................................................

.......................................................................................................

I am receiving from:
Alliance Pharmacy, The Morrisons Centre, Morton Park Way, Darlington DL1 4PJ.

I declare that the goods are being supplied to me for domestic or my personal use.

Signed: ................................................       Date:.............................

If the individual is unable to sign because of their disability or illness, a third party may sign on behalf of the named person. If you are a third party signing the above on behalf of someone else, please give your details below:

Name................................................................................................

Address.............................................................................................

Relationship to the named person above..................................................