SECONDARY CARE SECTION TO BE COMPLETED BY INITIATING DOCTOR NHS Number: Patient’s Name: Date of Birth: Date Treatment Started: (Add Date) One copy of information leaflet given to patient One copy of agreement sent to general practitioner One copy filed in patients notes Name of Initiating Doctor: Consultant: Speciality: Fax Number: 01902 695736 PRIMARY CARE SECTION TO BE COMPLETED BY GENERAL PRACTITIONER to enter into a shared care arrangement for the treatment of the above patient with I agree*/don’t agree* 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 and add read code 66S2 or XaK6z depending on GP clinical system. patient’s record BACK-UP ADVICE AND SUPPORT Contact details Telephone No. Email address: Rheumatology Nurse Helpline 01902 695491 01902 695492 Rheumatology Secretaries 01902 695495 Hospital Pharmacy Department 01902 695136 susan.reed4@nhs.net Mrs S. Reed
SECONDARY CARE SECTION TO BE COMPLETED BY INITIATING DOCTOR Patient’s Name: NHS Number: Date of Birth: Date Treatment Started: (Add Date) One copy of information leaflet given to patient One copy of agreement sent to general practitioner One copy filed in patients notes Name of Initiating Doctor: Consultant: Speciality: Fax Number: 01902 695736 PRIMARY CARE SECTION TO BE COMPLETED BY GENERAL PRACTITIONER I agree*/don’t agree* to enter into a shared care arrangement for the treatment 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 read code 66S2 or XaK6z depending on GP clinical system. BACK-UP ADVICE AND SUPPORT Contact details Telephone No. Email address: Rheumatology Nurse Helpline 01902 695491 Rheumatology Secretaries 01902 695492 01902 695495 Hospital Pharmacy Department Mrs S. Reed 01902 695136 susan.reed4@nhs.net
ESCA_Sodium_aurothiomalate_(Rheum)_Hosp_V1.1.docx