Independent Prescribing Proforma Additions Form Additions to Practice as an Independent Nurse or Pharmacist Prescriber Please complete this form electronically, then print, sign and arrange for manager and lead clinician to sign. Name: Role:
Base: Phone no:
Evidence Competence prescribe for disease area
of CPD undertaken supporting State items to be prescribed to prescribing within this area and guidelines worked to, or this attach protocols.
e.g. Asthma Diploma or 10 years experience (whatever is applicable)
e.g. Formal updates, courses attended (whatever is applicable) Please give as much information as possible including dates attended etc.
You may list individual items or make reference to guidelines or sections of BNF. Prescribing intentions must be clear and the evidence base identified.
Independent Prescribers signature: Date: My intended amended scope of prescribing practice has been discussed and agreed with m y manager and lead clinician
Independent Prescribing Proforma Additions Form Independent Prescribers Name: Managers Name: Managers Signature: Date: Lead Clinicians Name: Lead Clinicians Signature: Date: Please send the completed and signed form to Lucianne Ricketts Non Medical Prescribing Lead at PRCHC. along with an electronic version to â€“ Lucianne.Ricketts@kirkleespct.nhs.uk A copy should be retained by the Non Medical Prescriber and Manager.