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


About the escalation

Brief description as to why the patient is being escalated back to the practice
Brief description of the consultation undertaken by pharmacy
When does the patient require a response? (Please make sure patient is aware of this) *
Terms and Conditions *