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CD Requisition Form (Schedules 2 & 3)
A
Supplier Details
Invoice No.:
NHS Account Number / Wholesale
Dealer Licence / HO CD Licence No.:
Supplier’s Stamp:
Name of Business:
Telephone:
Address Line 1:
Address Line 2:
Address Line 3:
Postcode:
B
Controlled Drugs Requisitioned and Purpose
Drug Name
Strength and Unit
Form
Quantity
of Measure
Example: Buprenorphine
10mg / 100ml
Suspension
75 x 100ml
Purpose for which drugs are required (tick in box provided)
1
For use within Pharmacy
4
For Paramedic use
2
For use within Practice / Surgery
5
For Doctor’s bag
3
For use in independent hospital
6
Other (please state reason briefly below)
C
Customer Details
*See overleaf
* Individual Prescriber code / pharmacy’s NHS
(Part D, point 1(iii))
account number / CQC / HIS / HIW Number:
for guidance on
completion
* Practice, NHS Trust or NHS Provider Code:
Name of Practice:
Individual practitioner’s name (printed):
Professional qualification / occupation:
Address line 1:
Address line 2:
Telephone:
Postcode:
Date of Order / Supply
Signature: ____________________________
(NB: This must be the signature of the practitioner named above)
FP10CDF
© Crown copyright 2015
Print form
Reset form
Print form
CD Requisition Form (Schedules 2 & 3)
A
Supplier Details
Invoice No.:
NHS Account Number / Wholesale
Dealer Licence / HO CD Licence No.:
Supplier’s Stamp:
Name of Business:
Telephone:
Address Line 1:
Address Line 2:
Address Line 3:
Postcode:
B
Controlled Drugs Requisitioned and Purpose
Drug Name
Strength and Unit
Form
Quantity
of Measure
Example: Buprenorphine
10mg / 100ml
Suspension
75 x 100ml
Purpose for which drugs are required (tick in box provided)
1
For use within Pharmacy
4
For Paramedic use
2
For use within Practice / Surgery
5
For Doctor’s bag
3
For use in independent hospital
6
Other (please state reason briefly below)
C
Customer Details
*See overleaf
* Individual Prescriber code / pharmacy’s NHS
(Part D, point 1(iii))
account number / CQC / HIS / HIW Number:
for guidance on
completion
* Practice, NHS Trust or NHS Provider Code:
Name of Practice:
Individual practitioner’s name (printed):
Professional qualification / occupation:
Address line 1:
Address line 2:
Telephone:
Postcode:
Date of Order / Supply
Signature: ____________________________
(NB: This must be the signature of the practitioner named above)
FP10CDF
© Crown copyright 2015
D
Notes on using / obtaining FP10CDF forms
1.
The person raising the requisition (customer) must:–
i.
Write the controlled drugs to be requisitioned (including strength, form, quantity and unit of measure) in Part B
ii.
Indicate the purpose for which the drug(s) is / are required in Part B
iii. Write their name, individual / organisation code*, occupation / professional qualification (e.g. GP, pharmacist
or Vet), and address of work premises in Part C
iv. Sign their name at the bottom of Part C. Signature must be hand-written in ink
v. Complete the date of the order in Part C
* When requisitioning CDs for use in either an NHS practice or a private practice the following individual /
organisation codes are required:
A medical prescriber requires:
an individual prescriber code for each different NHS practice they work in
an individual private prescriber code for ‘private practice’
A non-medical prescriber requires:
an individual prescriber code plus NHS practice code for each practice they work in
an individual private prescriber code for ‘private practice’
* When requisitioning CDs for use in the veterinary sector, the practitioner’s MRCVS number must be provided
at Part C.
2.
The person / organisation supplying the controlled drugs (supplier) should either:
a. Write their account submission code (healthcare only), name of organisation, and address in Part A
OR
b. Include a legible stamp in the top left section of Part A, confirming their details
c. Ensure that the customer has completed their relevant sections with correct data
3.
Insert in Part A (where available):
the wholesaler’s invoice number for the requisition; and
either the NHS Account number, MHRA Wholesale Dealer Licence number or Home Office Controlled Drug
Licence number of the wholesaler.
The supplier must then submit all CD requisitions that they have processed to the NHS Business Services
Authority, using the FP34PCD form which should be downloaded from –
http://www.nhsbsa.nhs.uk/2473.aspx
(Note: Veterinary requisitions must not be sent to the NHSBSA but retained by the supplier in accordance with
legislative provisions).
4.
The FP10CDF form can be accessed at the NHSBSA website at
http://www.nhsbsa.nhs.uk/PrescriptionServices/1120.aspx
E
Data Protection Statement
This requisition will be passed to the NHS Business Services Authority (NHSBSA), a Special Health Authority in the
National Health Service (NHS), for the purposes of statistical analysis of what has been supplied. The information may
also be used within the NHS to prevent incorrect usage of controlled drugs, and may be disclosed to organisations
outside the NHS that have a lawful entitlement to receive it. This requisition will be confidentially destroyed 24 months
after the month in which it was received by the NHSBSA, unless it has been disclosed to another organisation.
2
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