GENERAL PRACTITIONER DETAILS:
Name: <DrName> 
Address: <DrAddress>
Provider Number: <DrProviderNo>
Prescriber No: <DrPrescriberNo>
Phone: <DrPhone>
Fax: <DrFax>
Email: <DrEmail>

Date of Pharmacist Review
 	PATIENT  DETAILS:

Name: <PtName>
Address: <PtAddress>
Medicare No: <PtMCNo>
DVA No: <PtDVANo>
Patient / carer contact: <Patient / carer contact>

Date of follow-up consultation: <Follow-up consultation>   jj	 CREDENTIALED PHARMACIST and COMMUNITY PHARMACY:

COMMUNITY PHARMACY DETAILS:
<AdrDetails>

CREDENTIALED PHARMACIST (if different):
Names: <Credentialed Pharmacist name>
Email: <Credentialed Pharmacist email>
Phone: <Credentialed Pharmacist phone no.>

CONDITION / FINDINGS / ISSUES RECOMMENDATIONS	CURRENT MANAGEMENT*	PROPOSED PLAN OF ACTION: 
Double click on box to highlight, type 'X' to check box.	PERSON RESPONSIBLE FOR ACTION**	EXPECTED OUTCOMES	PATIENT AGREES	

		q No action required 	q Action (comment):

		

	
		q No action required 	q Action (comment):

				
		q No action required 	q Action (comment):

				
		q No action required 	q Action (comment):

				
		q No action required 	q Action (comment):

				
		q No action required 	q Action (comment):

				

*pharmacological and/or non-pharmacological		** nominate other health care professional if applicable       

General Practitioner signature: _____________________________	Patient signature: _____________________________	Date _______________________           Copy to be offered to patient & Pharmacist		                                                                                                                                                                                                                                                             									
Attach an updated and reconciled medication list following the medication review