isotretconsentleadprescriber – Dickson Chemist

LEAD PRESCRIBER MHRA ISOTRETINOIN DECLARATION – can only be filled in once the patient has cmpleted consent – this is used at the end of the isotretinoin consultation.

Name of patient:

NHS/CHI number:

Hospital number:

Patient Form Entry ID (if known):

3.2 Lead Prescriber

I confirm that the possible risks of isotretinoin have been explained to the patient. These are detailed in the connected form completed by the patient with ID as above.

Pregnancy Prevention Programme status: (tick ‘Not applicable’, A, B or C, as appropriate). For patients in groups ‘Not applicable’, A and B, once stable on isotretinoin (after the first 1-3 months) the prescription may be for longer than 30 days (up to 12 weeks).

Not applicable (no childbearing potential)
Group A
Group B
Group C

Name of Lead Prescriber:

Role and unique identifier:

I believe this patient is suitable for isotretinoin therapy and it would be in their best interests to do so, I have sent the records for review to a second HCP and will not proceed until i have documented signed agreement from second HCP

Signature of lead prescriber

Clear Signature

Date / Time

Date

Time

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