Research Project Prescription Research project title: Chief Investigator: Patient name: CHI number: Date of birth: Participant ID number: Ward/Clinic Please supply the following for use in the above research project: Pack ID Drug Dose Frequency (if applicable) Prescriber’s signature: ________________________________________ Prescriber’s name printed: ________________________________________ Date: ________________________________________ ________________________________________ Ext./bleep: Please fax prescription to ARI Clinical Trials Pharmacy Fax No. 01224 551061 – PHARMACY USE ONLY Batch number: Expiry date: Pharmacist check: Dispensed by: Checked by: Date: Collected by:
Research Project Prescription Research project title: Chief Investigator: Patient name: CHI number: Date of birth: Participant ID number: Ward/Clinic Please supply the following for use in the above research project: Drug Dose Frequency Pack ID (if applicable) Prescriber’s signature: ________________________________________ Prescriber’s name printed: ________________________________________ Date: ________________________________________ Ext./bleep: ________________________________________ Please fax prescription to ARI Clinical Trials Pharmacy – Fax No. 01224 551061 PHARMACY USE ONLY Batch number: Expiry date: Pharmacist check: Dispensed by: Checked by: Date: Collected by:
TMP-QA-25_Research_Project_Prescription.docx