Community Practitioner prescribing Yes No (V150) only Do you have at least 2 years or equivalent relevant post registration experience? Independent/Supplementary prescribers Yes No (V300) only Do you have at least 3 years or equivalent relevant post registration experience? NMC PIN Expiry Date Allied Health Professionals Professional Group Please state area of practice Do you have at least 3 years or equivalent Yes No post qualification experience? HCPC registration Expiry Date number Optometrist Please state area of practice Do you have at least 2 years or equivalent Yes No post qualification experience? GOC registration Expiry Date number Pharmacist Please state area of practice Do you have at least 2 years or equivalent Yes No post qualification experience? GPhC registration Expiry Date number SECTION 3 Requirements for Prescribing Professional Qualifications Attained Awarding Body Level Year Subject Result Place of study Supporting Information (additional qualifications, professional experience likely to facilitate prescribing)
Community Practitioner prescribing (V150) only Do you have at least 2 years or equivalent relevant post registration experience? Yes No Independent/Supplementary prescribers (V300) only Do you have at least 3 years or equivalent relevant post registration experience? Yes No NMC PIN Expiry Date Allied Health Professionals Professional Group Please state area of practice Do you have at least 3 years or equivalent post qualification experience? Yes No HCPC registration number Expiry Date Optometrist Please state area of practice Do you have at least 2 years or equivalent post qualification experience? Yes No GOC registration number Expiry Date Pharmacist Please state area of practice Do you have at least 2 years or equivalent post qualification experience? Yes No GPhC registration number Expiry Date SECTION 3 Requirements for Prescribing Professional Qualifications Attained Awarding Body Level Year Subject Result Place of study Supporting Information (additional qualifications, professional experience likely to facilitate prescribing)
Staffs%20Regional%20Prescribing%20Application%20Form%20-%20Feb%2017_tcm44-93324.docx