Agreement between Patient and Pharmacist ~ Wolverhampton

ON FIRST ATTENDING THE PHARMACY TO COLLECT YOUR MEDICATION YOU MUST TAKE SOME FORM OF IDENTIFICATION WITH YOU OR THE PHARMACIST MAY NOT BE ABLE SUPPLY YOUR MEDICATION TO YOU.

The partnership is between:

  • Patient……………………………………… (Patient Name)
  • Pharmacist……………………………………… (Pharmacy Address)

Confidentiality – You are protected by the confidentiality boundaries of the service and you will not be discussed by partners unless it is necessary for the smooth running of your care.

Courtesy - We promise to treat you fairly, courteously and with respect at all times.

In return we ask of you the following:

  • You must attend in person from the named pharmacy within the times agreed between yourself and the pharmacist. Normally these will approximate to the Pharmacist’s hours of attendance within the premises, however we cannot guarantee you will be dispensed to if you arrive within …….……. of opening or closing time.
  • You should attend the Pharmacy alone except in exceptional circumstances, this is at the discretion of the Pharmacist.
  • You are required to keep your appointments with your Prescriber or Support Worker unless by prior agreement - Failure to attend may result in the stopping of or alterations to your treatment. If you are struggling to attend please discuss this with your key-worker.
  • Be responsible with any drugs you are prescribed. If you should lose them or take them other than directed, we cannot replace them.
  • Treat staff with courtesy and respect - threatening, abusive or violent behaviour will result in appropriate actionthat may affect your treatment.
  • Shoplifting or attempted shoplifting by you or anyone with you- will result in appropriate action that will affect your ability to have treatment at this Pharmacy.
  • Please attend in a fit state to be seen – if you appear intoxicated the pharmacist may refuse to dispense your medication.
  • Please keep all medicines out of the reach of children – we cannot stress too highly the importance of this as tragic accidents occasionally happen.

You can only have scripts dispensed at the named pharmacy – you cannot have the service provided elsewhere except by a prior arrangement discussed with your key-worker or other partner in the scheme.

You can only collect your prescription on the specified day - If you fail to collect a dose on the specified day you will not be able to collect that dose on a later day ,or later days on a multiday pick up ,unless script marked accordingly.

If you fail to collect your dose for three days or more your treatment will be reassessed - your tolerance may have altered.

I agree to comply with my obligations in the above agreement;

IT IS THE CLIENTS RESPONSIBILITY IF THEY ARE DRIVING TO INFORM THE DVLA THAT THEY ARE TAKING SUBUTEX OR METHADONE

Signed …………………………………………………………………………..

Pharmacist………………………………………………………………………….

Date…………………………………………………………..