GP-CPCS Non-Urgent Escalation Form

Please call the bypass number if you require a response within less than 4 working hours.

This form should only be completed by pharmacy staff on behalf of patients registered at The Alexandra Practice.

GP-CPCS Non-Urgent Escalation

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Section

Patient NHS Number:

Pharmacy Name: *

Pharmacy Phone Number: *

About the escalation

Reason for non-urgent escalation: *

Brief description as to why the patient is being escalated back to the practice

Who would be best placed to answer this query? e.g. GP, Nurse, HCA, Admin

Patients consultation notes: *

Brief description of the consultation undertaken by pharmacy

When does the patient require a response? (Please make sure patient is aware of this) *

Within 48 working hours

Within 5 working days

Terms and Conditions *

I have made the patient aware if the problem worsens and they require immediate help to contact NHS 111 Online or call 111, or in an emergency call 999.

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Section

About the escalation

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