Practice to pharmacy referral form
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A form for GPs and practice staff to refer their patients to a community pharmacy for a Medicines Use Review or to be enrolled in the New Medicines Service.
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Practice to pharmacy referral form
- 1. GP Practice to Community Pharmacist Referral Form Patient Name NHS Number Address Date of Birth Dear Pharmacist, I would be grateful if you could review the above patient as part of the: Referring GP /Nurse Date Site The Oaks Stoughton Road University of Surrey Wodeland Avenue GP-CP Referral Form v5 (Apr-14) Tel: 01483 409 309 Want to feedback on this form and its use? Please contact james.andrews@nhs.net Medicines Use Review (MUR) service Discuss and support adherence Synchronise medicine quantities Directed MUR Service NSAID Antiplatelet /Anticoagulant Diuretic Respiratory disease Hospital discharge in last 4 to 8 weeks New Medicines Service (NMS) Asthma COPD Type2 Diabetes Antiplatelet Anticoagulant Hypertension Please see new prescription for medicine(s) detail I have discussed the service requirement for information sharing between practice and pharmacist, and with other NHS organisations as appropriate (e.g. NHS England or BSA) Where available, please record in your feedback any measurement of, and advice given about: Smoking status Blood pressure Diet and nutrition Inhaler technique Physical activity Sexual health Alcohol intake Weight management Regular OTC medicines (e.g. low dose aspirin, analgesia, smoking cessation) Additional referral notes: Please complete and return a MUR or NMS feedback form for this patient OR