This is the text extract for Fax order form for close control resources, browse documents here.

FAX BACK TO 0800 455 442

To request further materials or information please complete the details below. Please send me:

Health Professional Information: Changes to the close control rules from 1 June 2008 Patient Information: Changes to the amount of medicine you receive

Number of copies: ________ Number of copies: ________

If you have any questions please write your message below: _________________________________________________________________________ _________________________________________________________________________

Our records currently show the following: Contact Name: Pharmacy/Surgery/Hospital Name: Postal Address: Physical Address: Telephone:

Fax:

Please amend my details as follows: Contact Name: _____________________________________________________________ Pharmacy/Surgery/Hospital Name: _____________________________________________ Postal Address: ____________________________________________________________ Physical Address:___________________________________________________________ Phone: (___)__________________________ E-mail: ___________________________________________________

Please remove me/this organisation from your list

qA797

«URN» - «MILID»