Applicant’s name:

Signature:

Date:

Generic name:

Therapeutic class:

Trade name and supplier:

Unit cost:

Is this drug on the national formulary list?

Proposed indications for use:

Principal mode(s) of action:

Major adverse effects and drug interactions:

Precautions and contraindications:

State prescribing restrictions, for example ‘specialist only’:

Are there prescribing guidelines?

Please attach

Average dose and frequency:

Average duration of therapy:

List drugs already approved for same indication:

List drug(s) to be replaced by requested drug:

Estimated number of patients per year:

Estimated annual expenditure on drug:

Advantages over listed alternative(s).

Please attach references.