Menopause Medical
Private Prescription Form
Prescriber Details
GMC Number
3461008
Qualification
General Practitioner
Name
Dr Samantha English
Clinic Name & Address
MMH
15 St Mary’s Chare,
Hexham
NE46 1NQ
15 St Mary’s Chare,
Hexham
NE46 1NQ
Tel
Email
Patient Details
Title
Name
D.O.B.
Tel
Email
Items
| Quantity | Item | Instructions |
|---|---|---|
I confirm that, as the prescriber:
- I declare that I have prescribed within my competencies, following best practice in accordance with the most current professional guidance.
- I am fully aware of and accept clinical, professional and legal responsibility for prescribing outside the licensed indications of any of the products wherever applicable.
- A face-to-face consultation with the patient has been completed.
- When I have considered it appropriate for another practitioner to administer this prescription, the named practitioner has been trained and I consider the said practitioner to be competent.
Prescriber’s Signature
Date