Methotrexate Education e-form

Methotrexate Education e-form
NHI*
Patient Full Name*

First NameLast Name
Date of Birth*

DayMonthYear
Free type or use calendar date picker
Ethnicity*
Town*
Informed consent | Healthify
I understand and agree to participate in a consultation with my Pharmacist. I consent to my pharmacist accessing relevant medical and hospital records to support my health care. I agree that anonymised data may be used to improve the service.
YESNOIf NO provide error
N/AOnce-a-week dosingSigns of toxicityMedicine interactionsSafe storage of MTX
Pharmacy Name (choose from list)*
Pharmacist Full Name*

First NameLast Name
Pharmacy Email
MUST be completed to receive a copy of PDF for pharmacy records
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
Consultation Date *

DayMonthYear
Free type or use calendar date picker
DOCUMENT VERSION CONTROL: Methotrexrate Consultation Form V1.0

PT NAME field hidden 15/12 as per Pete Chandler
Should be Empty: