Methotrexate Education e-form

Methotrexate Education e-form
Patient Information
NHI*
Date of Birth*

DayMonthYear
Free type or use calendar date picker
Ethnicity*
Town*
Informed consent | Healthify
Patient Consent*

Patient/Caregiver understands and agrees to participate in this service and consents for the pharmacist to access relevant medical records and share relevant information with other healthcare providers. They agree that anonymised data may be used to improve this service.
Consultation Data
Was the MTX prescription correct*

YESNOIf NO provide error
Patient demonstrated limited understanding of:*

N/AOnce-a-week dosingSigns of toxicityMedicine interactionsSafe storage of MTX
Pharmacist Declaration
Pharmacy Name (choose from list)*
Pharmacist Full Name*

First NameLast Name
Pharmacy Dispensary Email*
Free type or use calendar (Backdating lock enabled > 10 days)
Pharmacist Declaration:*

I agree that I have explained the consent process to the patient and have conducted a comprehensive consultation utilising the MidCPG Methotrexrate Consultation checklist.
Signature*

Clear
Pharmacist: Please check all fields are accurate before submitting. A report will be emailed to your dispensary email.
Consultation Date *

DayMonthYear
Free type or use calendar date picker
Patient Full Name (REMOVE via PETE 15/12/2025)*

First NameLast Name
Should be Empty: