Boots Pharmacy Outpatients

Medicines Use Review / New Medicine Service referral form

Patient name
Address
Telephone number
GP’s name
Nominated Community Pharmacy
Telephone number / Fax number / /
Medicines Use ReviewThis patient has been seen at Hospital Outpatient clinic and may be suitable for an MUR due to the following risk factors:
  • Changes in medicines (stopped/started/changed)......
  • High risk medicine (NSAIDs, anticoagulant, antiplatelet, diuretic)......
  • Compliance issues......
  • Aged over 75......
  • Polytherapy......
  • Kidney or liver problems......
  • Part way through dose escalation/reduction regime......
  • Has had medicine related problems in the past e.g. drug allergy, fall, hospital admission related to medicines......

New Medicines Service This patient has been seen at Hospital Outpatient clinic and has been prescribed a new medication for one of the following conditions:
  • Type 2 Diabetes......
  • Asthma......
  • COPD......
  • Hypertension......
  • Oral anticoagulant, antiplatelet......

Name of pharmacist referring...... Signature......
Date of referral......
Boots Outpatients Pharmacy, Royal Hallamshire Hospital, Glossop Road, S10 2JF, Sheffield,
Tel 0114 275 0317 Fax 0014 2755 307
Patient consent: I agree to a faxed a copy this referral being supplied to my nominated / usual community pharmacy for the purposes of a review of my medicines by a pharmacist. I understand that all information will be treated in the strictest confidence by personnel at the community pharmacy. I agree that the information obtained during the service can be shared with: my doctor (GP) to help them provide care to me, Sheffield Teaching Hospitals, the NHS England to allow them to make sure the service is being provided and NHS England, the NHS Business Services Authority (NHSBSA) and the Secretary of State for Health to make sure the pharmacy is being correctly paid by the NHS for the service they give me.
Patient signature...... Date......
If patient is not able to sign verbal consent obtained YES
For Community Pharmacy::
Name of Pharmacist...... Signature......
Date review completed...... Outcomes achieved......
......
Please fax completed form to Boots OP 0114 2755 307when service completed for monitoring purposes

The information contained within this fax transmission is intended only for the use of the individual or entity stated aboveItcontains information from Sheffield Teaching Hospitals NHS Foundation Trust that may be confidential and privileged. If you are not the intended recipient, you are hereby notified that any disclosure, copying, distribution or taking of any action in reliance on the contents of this information is strictly prohibited