High Risk Prescription Form

High Risk Prescription
Patient Name*

First NameLast Name
Patient Number*
Details of Prescription
Controlled medication(s) included in prescription (if applicable)
Risks and contraindications
Benefits and advantages
Rationale for prescribing controlled medications
Suggested viable/better alternative(s) proposed by the Pharmacist? (if applicable)
DECLARATION

I hereby undersign that;

a) the benefits of this prescription outweigh any potential side effects or risks associated with the controlled medications prescribed.

b) the benefits of this prescription outweigh any potential side effects or risks that have been identified by the Pharmacist.

c) the medications prescribed are the most appropriate and effective for the patient.
Name

First NameLast Name
Title
Signature

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Date

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Date
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