YOURmeds Referral & Consent Form

Section A

Applicant

Are you applying to use YOURmeds services yourself, or are you applying on behalf of another person?

Mezelf [Complete Section B, C, D, E & F]
On behalf of another person [Complete Section B, C, D, E, F & G]
Assessor please complete section H

Section B: User’s details

*Required Fields

Service User Identifier*
NHS Number*
Title*
First Name(s)*
Middle Name(s)
Last Name*
Date of Birth (DD/MM/YYYY)*
Phone Number*
Address Line 1*
Address Line 2
City*
Post Code*
Surgery Name*
GP Name*

Section C: Pharmacy Choice and Consent

How we will use your data to supply YOURmeds

We require your consent to enable the use of YOURmeds services. With your permission, we will use your NHS number to obtain details about your prescriptions and set up our services with your pharmacy.

We obtain information on the medication type and the prescription renewal date. This enables a smooth transition to our services, so that the right medication arrives on time.

Please see our privacybeleid for further details on how we use your data.

Please provide the details of your current pharmacy (required)

Name*
Address*

We will contact your pharmacy to set up your YOURmeds services. We will let you know once this is complete.

If your pharmacy decides not to work with us to provide the YOUR meds services or does not respond to us in a timely manner (we usually allow 2 days) you will need to choose a new pharmacy to dispense your prescriptions.

To avoid delays, you can decide now to choose an alternative pharmacy, if we are unable to provide YOURmeds services through your current pharmacy.

If we are unable to provide YOURmeds services through your current pharmacy, what would you like to do?

I will keep my current choice of pharmacy for now. I understand that, if YOURmeds is unable to provide services through my current pharmacy, I will be unable to access YOURmeds services at this time. [Go to Section F]
I wish to automatically switch my choice of pharmacy to a new pharmacy to receive YOURmeds services. I understand that my prescriptions will be sent to and dispensed by the new pharmacy.

If we are unable to provide YOURmeds services through your current pharmacy, with your permission, we can automatically switch your choice of pharmacy.

You can read more about choosing a pharmacy, and changing your choice, on the NHS website

You will be informed once we have renominated you to a Yourmeds pharmacy. Please inform the surgery of the pharmacy change. This eliminates the risk of medication being sent to the existing pharmacy.

NB : can the person completing this form also contact the surgery informing them of the pharmacy change.

Please tick here if you acknowledge this. (Required)*

Section D: About Your Medication

We need to programme a schedule on when to take your medicines. To enable you to be as adherent as possible, please try and have large timeframes per medication round. Please note that changes to your medication schedule will be done via your pharmacy.

Medication Round	Earliest Time	Latest Time
1
2
3
4
5
6
7
8
9
10

Next prescription date?
How many days of medication do you have currently?
What is the date today?

Section E: Supporters – Nominated Family and Friends

Please nominate at least 1 friend or family member that will receive a notification when a medication has been forgotten, they will be responsible for contacting and reminding you. As a nominated responder the person/s below are agreeing to receive medication alerts via the YOURmeds smartphone app.

*Required Fields

Responder 1 Name*
Phone*
Email*
Relationship to Patient
Responder 2 Name
Telefoon
E-mail
Relationship to Patient
Responder 3 Name
Telefoon
E-mail
Relationship to Patient
Responder 4 Name
Telefoon
E-mail
Relationship to Patient
Responder 5 Name
Telefoon
E-mail
Relationship to Patient

Should you wish to change the order of response please contact YOURmeds on 02392 470001 and ask for Technical Support.

Section F: Sharing your data with the NHS and local authorities

Through our services we aim to make medication simple, support people to stay independent, and reduce demand on NHS and social care services. With your permission, we would like to share data about your use of YOURmeds services with the NHS and local authorities to help evaluate the impact our services are having and to improve our services in future. We can only do so with your consent.

It is entirely up to you whether to give consent. Your choice will have no impact on access to our services and or the services you currently receive. You can withdraw consent at any time by contacting us.

Please see our privacybeleid for further details on how we use your data.

Do you consent to us sharing data about your use of YOURmeds services with the NHS and local authorities to help evaluate the impact our services are having and to improve our services in future?

Ja
Nee

Signature

Section G: Applying for another person – please provide your details

Naam
Adres
E-mailadres
Telephone
Please confirm your relationship to the applicant
Do you have the authority to apply for this service, and give consent on behalf of the applicant? Ja Nee

Sharing your data with the NHS and local authorities

Please see our privacybeleid for further details on how we use your data.

Do you consent to us sharing data about your use of YOURmeds services with the NHS and local authorities to help evaluate the impact our services are having and to improve our services in future?

Ja
Nee

Signature

Section H: Assessment Checklist and Medication

Why have you referred this user for a YOURmeds assessment?
What support is the user receiving currently to help with medication – med visits, memory reminders, does someone live with them?
How often does the supporter currently attend to help with medication?
Can the user change the medication pack in the switch unit	Ja Nee
If No, does this user have a supporter/carer who could attend on a weekly basis to change the medication pack	Ja Nee (If No, this user will require a weekly prescription in order to user the YOURmeds device)
Is the user on weekly or monthly prescriptions	Weekly Maandelijks

*Required Fields

Name of person completing this form*
Phone*
Email address*
Form submission date:

Once we receive the referral we will contact the person submitting the form to acknowledge receipt, if you do not receive an acknowledgment within 1 working day please contact your YOURmeds on 02392 470001.

Once completed download the form and upload it below.