CPCS urgent GP escalation

Important: For Community Pharmacy use only

This form is for staff of a Community Pharmacy to submit an escalation on behalf of a patient. If you are a patient, you cannot use this form and must contact us directly.

CPCS Urgent GP Escalation

Section

Patient NHS Number:

Pharmacy Name: *

Pharmacy Phone Number: *

About the escalation

Reason for urgent escalation: *

Brief description as to why the patient is being escalated back to the practice

Patients consultation notes: *

Brief description of the consultation undertaken by pharmacy

When does the patient require a response? (Please make sure patient is aware of this) *

Same day assessment or prescription

Routine response (up to 5 working days) or onward referral

Terms and Conditions *

I have made the patient aware if the problem worsens and they require immediate help to contact NHS 111 Online or call 111, or in an emergency call 999.

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Important: For Community Pharmacy use only

Section

About the escalation