Steroid Request – Dickson Chemist

Please use this form to request a steroid injection for your patient. Allow 48h for prescribing to occur.

Prescribers will charge £20 to write a prescription. The cost of each medicine is listed. If you want something else not listed, just leave a note in the notes section with your requirements.

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Patient Name

First

Last

DATE OF BIRTH

Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

to Physiotherapist Name

Name & Reg of Physiotherapist requesting steroid

Clinic address

I confirm I have clinically assessed the patient above and in my opinion would benefit from a steroid injection

AGREE

I confirm this patient has not had a steroid injection in the last 8 weeks and has no contraindications to local joint steroid therapy

AGREE

Choose product

If you want a product not listed please note it here