SMBG Review - Scope of Service & Pre-Authorisation

Practice Details
Practice Name & PCN*

Practice NamePCN
List Size*
GP Clinical System*

SystmOneEMIS
Contact Details
Admin/IT lead for system access*

NameNHS Email
Practice Manager*

NameNHS Email
Clinical Lead for project and approval of Pharmacist interventions*

NameNHS Email
Practice wishes to arrange a virtual meeting to discuss project*

YesNo
Pre Audit Checklist
Practice to share remote access to the GP system with rights to conduct drug searches and update medication records*

YesNo
Pharmacist Actions & Authorisation

Practice agrees to formulary alignment in relation to SMBG to the following formulary brands. Pharmacist to share patient list and leave an appropriate log of actions on completion*

	Authorisation (Y/N)
BGTS Change to Finetest Lite Glucose test strips
Lancets Change to Greenlan blood lancets
Needles Change to Greenfine Insulin pen needles

Practice preference for meter collection

	Authorisation (Y/N)
Practice agrees for the meters to be delivered to surgery via contact with NEON local rep/ customer services and signpost to patients accordingly
Patient to be signposted to NEON Customer Service to request direct delivery of meter

Neon customer services freephone helpline 0800 009 3378 info@neondiagnostics.co.uk
Please provide any additional comments or service requests below
I agree to the MMS HCP / Pharmacist implementing therapy changes in accordance with the criteria listed above.
GP Name & Date

GP NameDate
Signature

Clear
Please verify your submission*
Should be Empty:

Practice Details

Contact Details

Pre Audit Checklist

Pharmacist Actions & Authorisation

Practice preference for meter collection