Community Pharmacy Referral Form

Date

Community pharmacy referral form

To (GP practice name)

Patient’s name

Patient’s address

Patient’s DOB

NHS number

(where known)

This patient has been identified as having been prescribed more than 6 short-acting bronchodilator inhalers

without any corticosteroid inhaler within a 6-month period. The patient has agreed that you may be notified

of this, as there may be a need for their therapy to be reviewed.

Additional comments

(e.g. actions taken following intervention such as inhaler technique check and/or Medicines Use Review)

Pharmacy name

Address

Telephone

CONFIDENTIAL

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Parent category: Medical