Private Prescription:       Date:  

Practitioner details:  Email:    Tel:  

Patient details:   D.O.B:  

Address: Email:  Tel:  

Please describe the treatment that your products are going to be used for:  

• Is your patient pregnant or breast feeding?  
• Does your patient have a history of severe allergy/anaphylaxis, in particular allergies to hyaluronic acid, anaesthetics, or lidocaine?  
• Is your patient currently receiving any medical treatment? .If yes, details:  
• Has your patient previously received any aesthetic treatments, dermal fillers or botulinum toxin? .If yes, detail:  
• Does your patient suffer from any scalp issues? i.e. Scalp Psoriasis/Eczema, Scalp Herpes, Scalp Dermatitis or Scalp infection . If yes, details:  
• Does your patient have any skin infection or inflammatory problems (e.g., Herpes, acne)?  
• Is your patient currently taking any steroid, aspirin or anticoagulant?  
• Does your patient suffer from any mental health conditions? i.e. Untreated epilepsy, Focal Migraine, Depression  
• Does your patient suffer from any cardiac conditions? i.e. high/low blood pressure, fainting, heart attack, stroke or cardiac conduction disorders
• Do you have a neuromuscular disease eg MS ALS motor neuropathy myasthenia or Lambert-Eaton syndrome?  
• Do you have an autoimmune disease?  

Prescription item (s) :                                                                       Pharmacy Ref.

X Direction of useToxin-the appropriate units to be applied to the designated injection sites as directedTo be used for topical anaestheticTo be used in an anaphylactic emergencyDermal injection to be used for dermal filler treatmentKenalog-Intramuscular gluteal injection. One injection to be given. Max three per 12 monthsTo be used for reconstitutionTo be used as an intramuscular injection.To be used as manufacturer guidelines.Not prescribed and not to be dispensedUse 1ml twice daily on affected areas of scalp  

X Direction of useToxin-the appropriate units to be applied to the designated injection sites as directedTo be used for topical anaestheticTo be used in an anaphylactic emergencyDermal injection to be used for dermal filler treatmentKenalog-Intramuscular gluteal injection. One injection to be given. Max three per 12 monthsTo be used for reconstitutionTo be used as an intramuscular injection.To be used as manufacturer guidelines.Not prescribed and not to be dispensedUse 1ml twice daily on affected areas of scalp 

X Direction of useToxin-the appropriate units to be applied to the designated injection sites as directedTo be used for topical anaestheticTo be used in an anaphylactic emergencyDermal injection to be used for dermal filler treatmentKenalog-Intramuscular gluteal injection. One injection to be given. Max three per 12 monthsTo be used for reconstitutionTo be used as an intramuscular injection.To be used as manufacturer guidelines.Not prescribed and not to be dispensedUse 1ml twice daily on affected areas of scalp 

X Direction of useToxin-the appropriate units to be applied to the designated injection sites as directedTo be used for topical anaestheticTo be used in an anaphylactic emergencyDermal injection to be used for dermal filler treatmentKenalog-Intramuscular gluteal injection. One injection to be given. Max three per 12 monthsTo be used for reconstitutionTo be used as an intramuscular injection.To be used as manufacturer guidelines.Not prescribed and not to be dispensedUse 1ml twice daily on affected areas of scalp  

X Direction of useToxin-the appropriate units to be applied to the designated injection sites as directedTo be used for topical anaestheticTo be used in an anaphylactic emergencyDermal injection to be used for dermal filler treatmentKenalog-Intramuscular gluteal injection. One injection to be given. Max three per 12 monthsTo be used for reconstitutionTo be used as an intramuscular injection.To be used as manufacturer guidelines.Not prescribed and not to be dispensedUse 1ml twice daily on affected areas of scalp  

X Direction of useToxin-the appropriate units to be applied to the designated injection sites as directedTo be used for topical anaestheticTo be used in an anaphylactic emergencyDermal injection to be used for dermal filler treatmentKenalog-Intramuscular gluteal injection. One injection to be given. Max three per 12 monthsTo be used for reconstitutionTo be used as an intramuscular injection.To be used as manufacturer guidelines.Not prescribed and not to be dispensedUse 1ml twice daily on affected areas of scalp  

X Direction of useToxin-the appropriate units to be applied to the designated injection sites as directedTo be used for topical anaestheticTo be used in an anaphylactic emergencyDermal injection to be used for dermal filler treatmentKenalog-Intramuscular gluteal injection. One injection to be given. Max three per 12 monthsTo be used for reconstitutionTo be used as an intramuscular injection.To be used as manufacturer guidelines.Not prescribed and not to be dispensedUse 1ml twice daily on affected areas of scalp  

X Direction of useToxin-the appropriate units to be applied to the designated injection sites as directedTo be used for topical anaestheticTo be used in an anaphylactic emergencyDermal injection to be used for dermal filler treatmentKenalog-Intramuscular gluteal injection. One injection to be given. Max three per 12 monthsTo be used for reconstitutionTo be used as an intramuscular injection.To be used as manufacturer guidelines.Not prescribed and not to be dispensedUse 1ml twice daily on affected areas of scalp   

Prescriber details:   

Patient consultation date:

By signing this prescription, you confirm that you are aware of and accept clinical responsibility for all items prescribed for your patient. You also confirm that a face to face consultation has taken place or available/ offered to patient. If you have any questions, please call 02073239798 or email: prescription@wimpolepharmacy.co.uk

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Unique Document ID: 21f549810a06881ec341fd6b9ae5e86a48e9a929

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Timestamp	Audit
December 11, 2023 3:24 pm GMT	Hair plus- {{gravity-field-id-26}} Uploaded by Wimpole Pharmacy - sales@wimpolepharmacy.co.uk IP 176.104.33.6
December 11, 2023 4:47 pm GMT	Pharmacist Wimpole - prescription@wimpolepharmacy.co.uk added by Wimpole Pharmacy - sales@wimpolepharmacy.co.uk as a CC'd Recipient Ip: 81.106.114.117
December 11, 2023 4:50 pm GMT	Pharmacist Wimpole - prescription@wimpolepharmacy.co.uk added by Wimpole Pharmacy - sales@wimpolepharmacy.co.uk as a CC'd Recipient Ip: 81.106.114.117
March 11, 2024 2:11 pm GMT	Pharmacist Wimpole - prescription@wimpolepharmacy.co.uk added by Wimpole Pharmacy - sales@wimpolepharmacy.co.uk as a CC'd Recipient Ip: 81.106.114.117
March 11, 2024 2:52 pm GMT	Pharmacist Wimpole - prescription@wimpolepharmacy.co.uk added by Wimpole Pharmacy - sales@wimpolepharmacy.co.uk as a CC'd Recipient Ip: 81.106.114.117
April 1, 2024 1:46 pm GMT	Pharmacist Wimpole - prescription@wimpolepharmacy.co.uk added by Wimpole Pharmacy - sales@wimpolepharmacy.co.uk as a CC'd Recipient Ip: 81.106.114.117
May 15, 2024 4:46 pm GMT	Pharmacist Wimpole - prescription@wimpolepharmacy.co.uk added by Wimpole Pharmacy - sales@wimpolepharmacy.co.uk as a CC'd Recipient Ip: 81.106.114.117
May 15, 2024 9:42 pm GMT	Pharmacist Wimpole - prescription@wimpolepharmacy.co.uk added by Wimpole Pharmacy - sales@wimpolepharmacy.co.uk as a CC'd Recipient Ip: 81.106.114.117
December 9, 2024 3:35 pm GMT	Pharmacist Wimpole - prescription@wimpolepharmacy.co.uk added by Wimpole Pharmacy - sales@wimpolepharmacy.co.uk as a CC'd Recipient Ip: 176.104.33.6

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https://wimpolepharmacy.co.uk/

Audit Trail Serial# 2afcdf5ec1ddee76fabe14138beedfa4