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Appendix K

APPLICATION FOR APPROVAL TO UNDERTAKE NON-MEDICAL PRESCRIBING COURSE FULL NAME (print): ………………………………………………….. JOB TITLE: ……………………………………………………………. BASE OF WORK: …………………………………………………….. LINE MANAGER: ……………………………………………………… What do you intend to prescribe? (Please give a brief description of disease areas you intend to prescribe for, or state ‘formulary’ if applying for the nurse V150 course ):

……………………………………………………………………………………………………… ……………………………………………………………………………………………………… ……………………………………………………………………………………………………… ……………………………………………………………………………………………………… ……………………………………………………………………………………………………… ……………………………………………………………………………………………………… ……………………………………………… Do you have a (please tick): Medical Mentor

Non Medical Mentor

Name of mentor: ……………………………………………………………………………………………. Designation and place of work: ……………………………………………………………………………. Mentor contact details: ……………………………………………………………………………………………. Will prescribing only take place within the boundaries of NHS Kirklees? Y/N …………………………. If No, please state where: ………………………………………………………………………………………. Signature: ……………………………………………………. Date: ……………………………………………. Please return completed form WITH university application to: Non Medical Prescribing Lead Medicines Management Team Beckside Court Bradford Road Batley WF17 5PW


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