Den Ph1
Name of Accountable dentist: (GDP whose name appears on the dental
prescription pad)
…………………………………………………………………
(PRINT NAME)
DS Number:…………………..
Cypher number:……………….……..
Practice address
I authorise ……………………………………
GDC number: ……………………….
who is working as ………………………………………………. Dentist in my practice
to use my prescription pad under the following conditions:
-
He/she follows the advice outlined in ‘Prescribing matters for Dental
Practitioners’ Volume1, issues 1 and 2.(to be found at:
http://www.hscbusiness.hscni.net/services/2369.htm
-
A current copy of the BNF is available at the practice to consult at all times.
-
All prescriptions are entered in the prescription log held at the practice.
-
He/she prints their name alongside their signature inside the signature box.
-
The accountable dentist details and cipher number are not defaced/altered in
any way.
Signature of accountable dentist: …………………………………… Date: …………………
Signature of subsidiary:
prescribing dentist
…...……………………………… Date: …………….......