Dosette Box Referral – Dickson Chemist

Please fill in this form to refer for an assessment for a dosette box. Once completed, a technician will be in contact with the person to do an assessment and if appropriate start a dosette box.

DATE Email postcode

Patient Name:

First

Last

Contact Telephone Number

Address and postcode

DATE OF BIRTH

GP SURGERY

Name of person submitting this form (if not the patient)

Email for confirmation (optional)

Checkboxes

I understand I am giving consent to Dickson Chemist to register me for all appropriate NHS services in order to assess for, complete and deliver a compliance aid/dosette box/ MDS Tray to the patient listed above