Hair plus- {{gravity-field-id-26}}


Private Prescription:       Date:  

Practitioner details:  Email:    Tel:  

Patient details:   D.O.B:  

Address: Email:  Tel:  

  • Is your patient pregnant or breast feeding?  
  • Does your patient have a history of severe allergy/anaphylaxis, ?  
  • Is your patient currently receiving any medical treatment? .If yes, details:  
  • Has your patient previously received any aesthetic treatments, ? .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:  

Prescription item (s) :                                                                       Pharmacy Ref.

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X  

X  

X   

X   

X   

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X    

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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Signature Certificate
Document name: Hair plus- {{gravity-field-id-26}}
lock iconUnique Document ID: 668aa3011df37d930465474b3ef0de0cebf27fc3
TimestampAudit
December 11, 2023 3:24 pm BSTHair plus- {{gravity-field-id-26}} Uploaded by Wimpole Pharmacy - sales@wimpolepharmacy.co.uk IP 81.106.114.117
December 11, 2023 4:47 pm BSTPharmacist 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 BSTPharmacist 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 BSTPharmacist 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 BSTPharmacist 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 BSTPharmacist Wimpole - prescription@wimpolepharmacy.co.uk added by Wimpole Pharmacy - sales@wimpolepharmacy.co.uk as a CC'd Recipient Ip: 81.106.114.117