Private Prescription: Prescription Date:
Practitioner details:
Phone: / Email:
Patient details:
Phone: / Email:
Please describe the treatment that your products are going to be used for:
Prescription item (s) : Pharmacy Ref.
X
X
X
X
X
X
X
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 and that a suitable medical history, appropriate clinical assessment and physical examination has been undertaken. If you have any questions please call 0207-3239798 or email:
[email protected]
