Acid Reflux Pharmacist Consultation Form

Patient Name

First

Last

SECTION 1- Preconsultation Assessment

Patient Consent

obtained from the patient/carer who does not want to consult with their GP and would prefer to access treatment from the PGD user

Layout

Inclusion Checklist for the supply of proton pump inhibitors for gastro-oesophageal reflux disease (GORD)

Patients from 18 years of age.
Patients with endoscopically-determined gastro-oesophageal reflux disease (GORD).

Inclusion Checklist for the supply of esomeprazole 20mg capsules/tablets for reflux symptoms

Patients from 18 years of age with reflux symptoms

Tick the one that applies

Patient INcluded for endoscopically-determined gastro-oesophageal reflux disease (GORD) treatment
Patient INcluded for the supply of esomeprazole 20mg capsules/tablets

Exclusion Checklist for GORD

Exclusion Checklist supply of esomeprazole 20mg capsules/tablets for reflux symptoms

Tick the one that applies

Patient EXCLUDED for GORD Treatment
Patient EXCLUDED for Esomeprazole Treatment

SECTION 2 – Complete this session during consultation

Type of consultation

Video
Telephone
Walk In

Check patient ID presented e,g passport, Drivers License or Photocard

Passport
Drivers License
Photocard
Other

See caution and product interactions in PGD

Action if patient is excluded from the service

Discuss with patient and document the reasons for exclusion from treatment under the PGD.
• If the patient has consented, refer them to their GP and/or inform their GP.
• Signpost to other services if appropriate.
• Document the reasons for exclusion and any action taken, in the patient’s medication record.
• When treatment is postponed reschedule as appropriate.
If a serious complication or underlying pathology is suspected (e.g. oesophageal cancer), the patient should be urgently referred for further investigations.

Action if patient declines the service

Ensure patient/carer fully understands the risks of declining the service.
• Advise the patient/carer about the benefits of the service.
• Refer patient to GP if appropriate.
• Document the reasons for declining the service and any action taken, including advice given to the patient.
• Reschedule treatment if appropriate.
• Explain NHS eligibility for this service where appropriate.

Other, please specify

See PGD for dose, administration, adverse reaction

Healthcare Professional Name

First

Last

GPHC Number

Date