PATIENT AGREEMENT FORM

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					PATIENT AGREEMENT FORM
Patient Name: ……………………………………………………………………….

Address:      …………………………………………………………………………
              …………………………………………………………………………
              …………………………………………………………………………

Date of Birth: __/__/__

Telephone Number: ………………………………………………………………….


I am the patient named above; my doctor or member of the practice staff has
explained repeat dispensing to me. I have also been given a leaflet about
this.

I have read and understand the information given overleaf and what is
expected of me.

I agree to get my medicines (or other items) by the repeat dispensing method
and for information on my medication or treatment to be exchanged between
my GP and the pharmacist.

Patient/Guardian Signature:……………………………………………………..

Date: __/__/__

Doctor’s name; Practice name, address and telephone number




Signature of Doctor/Practice Staff: …………………………………………………

(Duplicate copies retained by practice and patient).
 Name, address and telephone number of nominated pharmacy




I (the patient) understand that:
 My doctor will give me an “authorising” repeat dispensing prescription
  (the form with “RA” printed on it) and a number of repeat dispensing
  issue forms (forms with “RD” printed on them).

 The pharmacy will keep the “authorising” repeat dispensing
  prescription and repeat dispensing issue forms.

 I should not sign all the repeat dispensing issue forms in one go. I
  should complete Part 1 or Part 2; and sign Part 3 on the reverse of the
  form, when I collect a repeat from the pharmacy (or get a
  representative to do this for me).

 If I pay prescription charges I understand I must pay a prescription
  charge each time the prescription is repeated.

 I should contact the pharmacy (not the doctor) whenever I need more
  medicines or other items until all the repeat dispensing forms are used
  up. When this happens, I understand that I will need to go back to my
  doctor and get another set of repeat dispensing forms.

 I have to use a single pharmacy for all my repeat dispensing. If I want
  to change to another pharmacy, I understand that I will need to go back
  to the doctor and ask him/her if he/she will reissue all the necessary
  forms for the new pharmacy.

 My pharmacist does not have to give me every item listed on the
  repeat dispensing issue form if I do no require them (for instance, if I
  have plenty of medicine left at home).

 I should let my pharmacist know about other medicines given to me, so
  s/he can check it is safe to take these with my repeat dispensed
  medicine. I should tell my pharmacist about other medicines given:

      After a hospital or dental appointment etc.
      From another pharmacy (including non-prescription items such as
       cough/cold remedies); or
      Herbal or other “alternative” medicines.
      I should tell my pharmacist if I stop taking medicines for any reason.

				
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posted:9/16/2012
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