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YOUR DETAILS

Please note that if we are unable to verify your contact details then unfortunately we will not be able to respond to the enquiry. This is to ensure that we can maintain our service to all of our enquirers.

Your Name:

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Work Address:

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Work Phone No:

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NHS Email:

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Job Description:

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Please selectCommunity PharmacistCommunity/District NurseGeneral PractitionerMidwifeOtherPCT AdviserPolice/prison officerPractice Nurse/Health VisitorPractice PharmacistStrategic HA adviser

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PRIMARY CARE TRUST

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Please selectBradford & Airedale TeachingCalderdaleCounty DurhamCumbriaDarlingtonEast Riding of YorkshireGateshead HartlepoolHull TeachingKirkleesLeedsMiddlesbroughNewcastleNorth TynesideNorth Yorkshire & YorkNorthumberland Care TrustRedcar & ClevelandSouth TynesideStockton on TeesSunderland TeachingWakefield

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YOUR ENQUIRY

Please state your
 enquiry in a clear
and precise manner

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PATIENT INFORMATION

Please provide an identifier for this enquiry that we can use when contacting you with the answer or if further details are required. To maintain confidentiality please do not use the patient’s name as the identifier.

Patient Identifier:

Age:

Gender:

Medical details:

Medication details:

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Click on the “Send” button to submit your enquiry. If the form has been processed successfully you will be directed to a new page which will confirm the details sent.