Patients & visitors

NHS Borders Pharmacy Specials Authorisation Form

Glasgow have kindly shared a useful alphabetical list of alternatives to some commonly prescribed Unlicensed Medicines. Please check this list before proceeding to complete the e-form below

Specials A-Z GGC June 2022

Please complete all the fields in this form and then select Submit. This will be picked up by a member of the Community Pharmacy team and your response will be emailed back to you.

For urgent requests please phone 01896 827712

I have checked and the product does not have a UK product licence and is not listed in part 7S or 7U of the Drug Tariff (click box to confirm) *

Requesting Pharmacy *

Telephone Number *

Contractor Code *

Pharmacy Contact Name *

Name of pharmacist in charge who has approved the ordering of this item? *

Pharmacist Email Address

Has the pharmacist in charge contacted the prescriber regarding this item? *

Please provide details of why a special is required as per Drug Tariff Part 1, Section 14. *

e.g. No licensed product in liquid formulation for a child unable to swallow caps

Indication *

Prescription Type? *

Product Name *

e.g. Melatonin (KidNaps)

Product Strength *

e.g. 1mg/ml

Product vehicle or formulation if applicable *

e.g. Liquid

Quantity Prescribed *

e.g. 100ml

Dose *

e.g. 5ml daily

Supplier Name *

e.g. IDIS

Expected cost for prescription item (excluding Out of Pocket Expenses) *

Out of Pocket Expenses include Handling Charges and Postage + Packaging

Expected Handling Charge?

Expected Post & Packaging?

Expected Other Out of Pocket Expenses? (please detail as per Drug Tariff Part 1, Section 18) *

Patient CHI *

Patient Initials *

Prescriber's Name? *

Prescriber's Reference Number? *

5-digit number normally beginning with 5 or B

Prescriber's Practice Number? *

5-digit number normally beginning with 16 or B

Unlicensed Medicines (Specials)

NHS Borders Pharmacy Specials Authorisation Form

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