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