Gout Uric Acid Point of Care Test e-form

Gout Uric Acid Point of Care Test e-form
Patient Full Name*

First NameLast Name
NHI*
Date of Birth*

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

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.
URIC ACID TEST

Maximum 2 funded tests per patient. IF, uric acid test #1 was completed at the initial consultation, enter into field #2.
Reason for Uric Acid Point of Care Test*

OpportunisticNon adherent with gout medicinesCant get to labMonitoringNo lab form from DrOther
Uric Acid PoC #1

YESUric Acid Level (mmol/L)
Uric Acid PoC #2

YESUric Acid Level (mmol/L)
Pharmacy Name (choose from list)*
Pharmacist Full Name*

First NameLast Name
Pharmacy Email*
MUST be completed to receive copy of PDF for pharmacy records
Pharmacist Declaration*

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

Clear
Date of Uric Acid Test *

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

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

URIC ACID TEST