Referring Doctor: <DrName>                 Provider No: <DrProviderNo>	
Practice Name: <LocationName>	
Address: <LocationAddress>	
Phone: <DrPhone>    Fax: <DrFax>	

Dear NWRH EDMS office, 
Here is the information you need to provide a THS prescription for Gabapentin prescription for:

Patient Name: <PtFullName>    DOB: <PtDoB>	
Address: <PtStreet>, <PtCity>, <PtPostcode>	
Phone (home): <PtPhoneH>    (Mobile): <PtPhoneMob>	
Medicare: <PtMCNo>    Concession: <PtPensionNo> 	

Current Medications:
<SelectedRx>	

Relevant Intercurrent Medical Conditions:
<SelectedPMH>	

Allergies:
<Reactions>	

I, <DrName>, understand and acknowledge the following:

I acknowledge the following: 	(Y/N)	
1.	That I, the GP, remain the patient's physician & actively manage my patient's chronic pain 		
2.	That the THS , will co-prescribe only  if I forward sufficient information for you to do so safely		
3.	That  the THS  does not see the patient and rely solely on the clinical information I provide		
4.	That this patient is unable to take Pregabalin because:		
•	Medication Allergy		
•	Significant side effects		
•	Medication is ineffective		
•	Other, please specific		
5.	That this patient is not to contact the THS , and any queries will be directed through to me, the GP		

I declare that: 	(Y/N)	
1.	I last reviewed this patient's pain management protocol today		
2.	The possible use of Amitriptyline or Nortriptyline has been considered		
3.	The possible use of Duloxetine or Venlafaxine has been considered		
4.	The use of allied health input has been  maximised		
I (the GP) declare that a Tricyclic, SNRI and other appropriate medications  and  allied health assistance has been considered and discussed with <PtFullName>		

Prescription details:	Please provide details:	
1.	The patient has been on Gabapentin for?		
2.	The Gabapentin was initially prescribed by? (Doctors name)		
3.	The patient is on Gabapentin as treatment for? (medical condition)		
4.	The dosage of Gabapentin I am requesting is		
5.	Where does your patient wish to collect their prescription?	
•	NWRH Pharmacy		
•	Mersey Community Hospital Pharmacy		
•	Other prescription collection point - please specify		

Sincerely

<DrName>	Date: <TodaysDate>