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Nthly Direct Debit instalments. Mr Mrs Miss Ms Other Important note: you can only pay by Direct Debit if you buy a 12 month certificate. Surname First name Date of birth How would you like to pay? Are you the account holder? / / (Important - we need to know this so we can check you are not entitled to free prescriptions) National Health Service number Where should we send your certificate? (Please give your full address including postcode.) House number or name Street No Yes.

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