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"
*
" indicates required fields
About the Requestor:
Requester Name
*
First
Requester Company
*
Purchase Order No' (to the value of £35.00 +vat)
*
Requesters telephone number
*
Requesters Email address
*
Company RISQS ID no’
*
_____________________________________________________________________________________________________
Patient Details:
Patient Name
First
Patient Date of Birth (dd/mm/yyyy)
Patient Email Address
Patient Contact Number
Patient Job Title
Is It a Safety Critical Role?
Yes
No
Does the patient ever work alone?
Yes
No
Has the patient been referred by an Occupational Health provider?
Yes
No
Patient's Line Manager (if not above)
First
Line Manager Contact Number
Line Manager Email Address
*The pharmacist may wish to contact the patient to discuss potential side effects
_____________________________________________________________________________________________________
Medication Details:
Name of medication being taken
Strength (milligrams)
Dosage (daily intake)
How long has medication been taken for?
Last Dosage taken (date / time)
Has the patient taken this medication before?
Yes
No
Has the patient experienced any side effects? (Details: i.e., dizziness)
_____________________________________________________________________________________________________
Medication 2 Details (if applicable):
Name of medication being taken
Strength (milligrams)
Dosage (daily intake)
How long has medication been taken for?
Last Dosage taken (date / time)
Has the patient taken this medication before?
Yes
No
Has the patient experienced any side effects? (Details: i.e., dizziness)
_____________________________________________________________________________________________________
Medication 3 Details (if applicable):
Name of medication being taken
Strength (milligrams)
Dosage (daily intake)
How long has medication been taken for?
Last Dosage taken (date / time)
Has the patient taken this medication before?
Yes
No
Has the patient experienced any side effects? (Details: i.e., dizziness)
_____________________________________________________________________________________________________
Medication 4 Details (if applicable):
Name of medication being taken
Strength (milligrams)
Dosage (daily intake)
How long has medication been taken for?
Last Dosage taken (date / time)
Has the patient taken this medication before?
Yes
No
Has the patient experienced any side effects? (Details: i.e., dizziness)
}
