nhs forth valley formulary 11 - Community Pharmacy

Forth Valley Formulary Eleventh Edition 2012/13Appendix 2FORTH VALLEY ACUTE HOSPITALSPHARMACY SERVICESREQUEST FOR A NON-FORMULARY DRUGWS-S-712IssueDate:May11ReviewDate:May 2013This form should be completed by the PRESCRIBER for initiation of a non-formulary drug if the drugis prescribed for this patient for the first time in this hospital.The form should then be forwarded to the responsible CONSULTANT for counter signature.The completed form should then be returned to the clinical ward pharmacist who will retain thedocument in the pharmacy department.These forms will be monitored and audited on a regular basis.Part A: Patient DetailsPatient Name/Details:Reason for admission:Consultant:Ward:Clinical pharmacist:Name(generic and proprietary):Part B : Drug DetailsForm: Strength: Dose:Indication:No equivalent Drug:Part C : Reason Formulary Product is not suitableNo equivalent Form of Administration:MoreEffective:Less Side Effects, Specifically………………….Other:Prescriber (printed):………………………………….Signature:………………………………Date:………………….Consultant (printed):………………………………….Signature:………………………………Date:………………….Part D: Pharmacy UsePrice (include VAT) - per packsize:- per daily doseComment:Clinical Pharmacist (printed):Signature:Page 51