Private Prescription:  Date:  

Practitioner details: 

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Patient details:

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

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. 

  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. Max three per 12 monthsTo be used for reconstitutionTo be used as an intramuscular injection.To be used as manufacturer guidelines.

  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. Max three per 12 monthsTo be used for reconstitutionTo be used as an intramuscular injection.To be used as manufacturer guidelines.

  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. Max three per 12 monthsTo be used for reconstitutionTo be used as an intramuscular injection.To be used as manufacturer guidelines.

  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. Max three per 12 monthsTo be used for reconstitutionTo be used as an intramuscular injection.To be used as manufacturer guidelines.

  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. Max three per 12 monthsTo be used for reconstitutionTo be used as an intramuscular injection.To be used as manufacturer guidelines.

  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. Max three per 12 monthsTo be used for reconstitutionTo be used as an intramuscular injection.To be used as manufacturer guidelines.

  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. Max three per 12 monthsTo be used for reconstitutionTo be used as an intramuscular injection.To be used as manufacturer guidelines.

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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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Timestamp	Audit
July 14, 2022 11:07 pm BST	Prescriber - {{gravity-field-id-26}} Uploaded by Wimpole Pharmacy - sales@wimpolepharmacy.co.uk IP 81.106.114.117
July 19, 2022 2:08 pm BST	Wimpole Pharmacist - prescription@wimpolepharmacy.co.uk added by Wimpole Pharmacy - sales@wimpolepharmacy.co.uk as a CC'd Recipient Ip: 82.44.198.103
August 18, 2022 12:11 pm BST	Wimpole Pharmacist - prescription@wimpolepharmacy.co.uk added by Wimpole Pharmacy - sales@wimpolepharmacy.co.uk as a CC'd Recipient Ip: 82.44.198.103
December 9, 2022 3:02 pm BST	Wimpole Pharmacist - prescription@wimpolepharmacy.co.uk added by Wimpole Pharmacy - sales@wimpolepharmacy.co.uk as a CC'd Recipient Ip: 82.44.198.103
February 10, 2023 10:56 pm BST	Wimpole Pharmacist - prescription@wimpolepharmacy.co.uk added by Wimpole Pharmacy - sales@wimpolepharmacy.co.uk as a CC'd Recipient Ip: 86.4.245.59
February 10, 2023 10:58 pm BST	Wimpole Pharmacist - prescription@wimpolepharmacy.co.uk added by Wimpole Pharmacy - sales@wimpolepharmacy.co.uk as a CC'd Recipient Ip: 86.4.245.59
February 14, 2023 11:20 pm BST	Wimpole Pharmacist - prescription@wimpolepharmacy.co.uk added by Wimpole Pharmacy - sales@wimpolepharmacy.co.uk as a CC'd Recipient Ip: 86.4.245.59
February 15, 2023 12:59 pm BST	Wimpole Pharmacist - prescription@wimpolepharmacy.co.uk added by Wimpole Pharmacy - sales@wimpolepharmacy.co.uk as a CC'd Recipient Ip: 86.4.245.59
February 22, 2023 12:26 pm BST	Wimpole Pharmacist - prescription@wimpolepharmacy.co.uk added by Wimpole Pharmacy - sales@wimpolepharmacy.co.uk as a CC'd Recipient Ip: 86.4.245.59
March 1, 2023 4:59 pm BST	Wimpole Pharmacist - prescription@wimpolepharmacy.co.uk added by Wimpole Pharmacy - sales@wimpolepharmacy.co.uk as a CC'd Recipient Ip: 86.4.245.59
April 25, 2023 10:46 pm BST	Wimpole Pharmacist - prescription@wimpolepharmacy.co.uk added by Wimpole Pharmacy - sales@wimpolepharmacy.co.uk as a CC'd Recipient Ip: 86.4.245.59
April 26, 2023 9:20 pm BST	Wimpole Pharmacist - prescription@wimpolepharmacy.co.uk added by Wimpole Pharmacy - sales@wimpolepharmacy.co.uk as a CC'd Recipient Ip: 86.4.245.59
March 11, 2024 2:07 pm BST	Wimpole Pharmacist - 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 2:54 pm BST	Wimpole Pharmacist - prescription@wimpolepharmacy.co.uk added by Wimpole Pharmacy - sales@wimpolepharmacy.co.uk as a CC'd Recipient Ip: 81.106.114.117
March 17, 2024 12:19 pm BST	Wimpole Pharmacist - prescription@wimpolepharmacy.co.uk added by Wimpole Pharmacy - sales@wimpolepharmacy.co.uk as a CC'd Recipient Ip: 81.106.114.117
March 19, 2024 11:25 am BST	Wimpole Pharmacist - 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 4:19 pm BST	Wimpole Pharmacist - prescription@wimpolepharmacy.co.uk added by Wimpole Pharmacy - sales@wimpolepharmacy.co.uk as a CC'd Recipient Ip: 81.106.114.117

This audit trail report provides a detailed record of the online activity and events recorded for this document.

https://wimpolepharmacy.co.uk/

Audit Trail Serial# 2afcdf5ec1ddee76fabe14138beedfa4