Formulary amendment

Information about you

Your name

Your role

Your organisation

Information about the drug

Generic name and trade name

Formulation and presentation

Intended patient group

Usual dose and administration schedule

Current therapy prescribed for this indication

Information to support the formulary amendment

What place will this have in the formulary?

Will this replace a current formulary medicine or is it an addition to the current medicines formulary?

What advantages does this product offer over existing therapy?

Please consider clinical, financial, and patient factors.

Why do you want to use it?

Will there be an increased or decreased demand for other services?

For example, blood monitoring. If so, please specify.

How many patients do you anticipate prescribing for each year?

Please state if this figure is per practice or per hospital.

What are the cost implications?

Signatories

Name of your APC representative

This is the person who attends the monthly APC meeting for your organisation.

Declaration

I have discussed this suggested formulary amendment with my APC representatvive named above.

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