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TO THE .............................................................................................................................................................
FHSA
1. I/We..........................................................................................................................................................
of ..............................................................................................................................................................
(a) apply in my/our own right/on behalf of .......................................... to be included in the FHSA's pharmaceutical list(s) for the provision of the services listed in paragraph 6 below. I/We are not already included in any pharmaceutical list kept by the FHSA;
(b) am/are already included in a pharmaceutical list kept by the FHSA, but apply to open additional premises for the provision of the services listed in paragraph 6 below;
(c) am/are already included in a pharmaceutical list kept by the FHSA, but apply to relocate the premises from which I/we are to provide the services listed in paragraph 6 below;
(d) am/are already included in a pharmaceutical list kept by the Authority, but apply to provide from my/our existing premises additional services to those already provided;
(e) am/are already included in a pharmaceutical list kept by the FHSA, but apply to withdraw the provision of a service/services from an existing premises.
2. (To be completed only by persons applying under paragraph 1(a), (b), (c) or 4)
(a) The premises from which I/we wish to provide those
services are at.................................................................................................................................
......................................................................................................................................................
......................................................................................................................................................
(b) Those premises are-already constructed
- already in my/our possession/not yet in my/our possession (by rental, leasehold or freehold)
- under negotiation
- registered by the Royal Pharmaceutical Society of Great Britain If so, state reference number
.........................................................................................................................................................
3. (To be completed only by persons who are included in a pharmaceutical list kept bytheAuthonty) The premises from which I/we provide pharmaceutical
services are at .......................................................................................................................................
.................................................................................................................................................................
The services I/we provide from those premises are.......................................................................
...............................................................................................................................................................
4. (To be completed only by persons applying under paragraph 1(a) above who are proposing to provide services at premises from which services are already provided ie change of ownership)
The name of the chemist who is providing services from the premises named in paragraph 2(a) above is
..............................................................................................................................................................
..............................................................................................................................................................
The provision of services from those premises will be
continuous/interrupted by (state period) ......................................................................................................
...............................................................................................................................................................
5. (To be completed only by persons applying under paragraph 1(c) above)
The relocation is for the following reasons:-
...............................................................................................................................................................
..............................................................................................................................................................
(To be completed only tf the applicant considers relocation to be minor
I/We consider the relocation to be minor for the following reasons:-
............................................................................................................................................................
............................................................................................................................................................
The provision of services by me/us will be
continuous/interrupted by (state period) ..................................................................................
............................................................................................................................................................
6. (To be completed by all applicants)
I/We propose to provide/withdraw the following pharmaceutical services
PROVISION OF DRUGS
PROVISION of the following listed appliances:-
OXYGEN CYLINDERS
STOMA APPLIANCES
ELASTIC HOSIERY
TRUSSES
OTHER APPLIANCES (please specify)
..........................................................................................................................................................
OTHER SERVICES (please specify)
...........................................................................................................................................................
7. (To be completed by all applicants except those proposing either to provide services from premises from which the services listed in paragraph 6 are already provided or to change within the neighbourhood the premises from which pharmaceutical services listed in paragraph 6 are already provided)
In my/our view the provision of the proposed services at the premises named in this application is necessary or desirable in order to secure in the neighbourhood in which the premises are located the adequate provision of those services by persons in the list of services for the following reasons:-
........................................................................................................................................................
........................................................................................................................................................
8. I/we undertake that if my/our application is granted, I/we will provide/continue to provide
the pharmaceutical services specified in paragraph 6 at the premises specified in paragraph 2.
Signed ...........................
Date ...............................
*The sections or words which do not apply should be deleted as necessary.
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| Book Title: Pharmaceutical Regulations | ||