GPhC – Expression of Interest and Consent form

GPhC pilot themed review of good clinical governance in community pharmacy settings

Pharmacy details

GPhC-registered name of the pharmacy*

GPhC pharmacy premises registration number*

Postcode of pharmacy premises*

Hidden

Location of pharmacy in UK country

Location of pharmacy in UK country*

(Indicate ‘England’, ‘Scotland’, or ‘Wales’)

Size of pharmacy business*

(Number of pharmacy branches in the business)

Please indicate type of pharmacy business model*

(Especially if your pharmacy includes, for example, emerging advanced clinical prescribing roles, new automated technologies, different ways of working, online pharmacy, providing remote consultations)

Contact details of individual completing this form, expressing interest

Name*

First Last

Position in pharmacy business/job role*

Email address*

Phone*

Expression of interest*

I am interested in sharing my experience with the GPhC as part of the pilot themed review of what good clinical governance looks like in community pharmacy settings.

Consent

By completing and submitting this form to the NPA:*

I give consent for the NPA to share the information in this form with the GPhC; this includes sharing my name and contact details (as stated above) with the GPhC.

I also give consent for the GPhC to contact me in relation to the pilot themed review of good clinical governance.

CAPTCHA

Comments

This field is for validation purposes and should be left unchanged.