Sharnbrook Surgery - QRISK and Statin Decision

Required field(s) are indicated by *
This form is to be completed if you have received a letter about your QRISK score and have consequently been offered treatment with a Statin.

Who are you completing this form on behalf of?*

MyselfSomeone else (e.g. child or dependent)

Full Name:*

First Name(s)Last Name(s)

Postcode:*

Date of Birth:*

Sex:*

MaleFemaleOther

Your Phone Number*

The practice may use this number to contact you about your request.

Email*

This email address can be used to contact you about your request. Please be aware that if you have given anyone else access to your email account they may see responses sent to you.

Please select one option from the below. *

I would like to be prescribed a Statin - A prescription for Atorvastatin 20mg one to be taken daily will be added to your repeat and the prescription will be sent to your usual nominated pharmacy within 5 working days. You will be required to book a blood test to check your liver and cholesterol in 3 months time then again after 12 months.I would like to decline a Statin - This will be noted in your records. Please be aware that you may still be asked to consider a Statin at a later date.I would like an appointment to discuss this further - One of our reception team will call you and book you an appointment with either a GP or a Clinical Pharmacist.

Patients Name*

As it appears on the patient's passport.As it appears on the patient's passport.

Postcode*

The one you used to register with your GP.

Patients Date of Birth*

Patient's date of birth is required to verify their identity.

Sex*

MaleFemaleOther

Your relationship to the Patient*

Postcode*

Full Name*

First NameLast Name

Date of Birth*

Your date of birth is required to verify your identity.

Sex*

MaleFemaleOther

Your Phone Number*

The practice may use this number to contact you about your request.

Email*

This email address can be used to contact you about your request. Please be aware that if you have given anyone else access to your email account they may see responses sent to you.

Please select one option from the below.*

I would like to be prescribed a Statin - A prescription for Atorvastatin 20mg one to be taken daily will be added to your repeat and the prescription will be sent to your usual nominated pharmacy within 5 working days. You will be required to book a blood test to check your liver and cholesterol in 3 months time then again after 12 months.I would like to decline a Statin - This will be noted in your records. Please be aware that you may still be asked to consider a Statin at a later date.I would like an appointment to discuss this further - One of our reception team will call you and book you an appointment with either a GP or a Clinical Pharmacist.

QRISK and Statin Decision form

About the patient

About you