EmailMe Form - Contact Consent

Update your contact details

I consent to CookStPharmacy contacting me regarding prescriptions and other matters that may arise.

For me

For my family members who I confirm agree too

Please check ONE or BOTH boxes. By checking these you agree to be sent communication via electronic means either for you, or the people CookStPharmacy understand are part of your immediate family, or both.

Name

First Last

I consent to being sent emails and other electronic communication from CookStPharmacy

Email

Please enter the email address we're to contact you at.

Confirm

Phone

### - ### - ####

If we need to get in touch a phone number is handy.