Methotrexate is NOT licensed for the following indications but there is a good body of medical evidence that supports its use:- One copy filed in patient record One copy of agreement sent to general practitioner Name of Initiating Doctor: Speciality: Consultant: Fax number Patient Name: NHS Number: SECTION TO BE COMPLETED BY GENERAL PRACTITIONER I agree* to enter into a shared care arrangement for the treatment and monitoring of the agree*/don’t above patient with this medicine (*delete as appropriate) GP Name: Signature: Date: Once signed please detach this sheet and fax to the number shown above. File copy in record and add shared care specialist/GP read code 66S2 or XaK6z depending on patient’s – GP clinical system.
Methotrexate is NOT licensed for the following indications but there is a good body of medical evidence that supports its use:- One copy filed in patient record One copy of agreement sent to general practitioner Name of Initiating Doctor: Speciality: Consultant: Fax number Patient Name: NHS Number: SECTION TO BE COMPLETED BY GENERAL PRACTITIONER I agree*/don’t agree* to enter into a shared care arrangement for the treatment and monitoring of the above patient with this medicine (*delete as appropriate) GP Name: Signature: Date: Once signed please detach this sheet and fax to the number shown above. File copy in patient’s record and add shared care – specialist/GP read code 66S2 or XaK6z depending on GP clinical system.
ESCA_Methotrexate_V1.docx