Shared Care Application Form– ISC-CARE LIMITED
This form is for existing clients of ISC-CARE who are suitable for applying for shared care agreement with their GP.
Before continuing with the application, please confirm that you have been stable on your current dosage for at least 8 weeks? (if the answer is no, then please do not continue with this application form)
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Yes
Client Details Section
Name
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First Name
Last Name
Date of Birth
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Month
-
Day
Year
Date
Email
*
example@example.com
Phone Number
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GP name and address
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Baseline Health Information
Blood Pressure (mmHg)e.g., 120/69
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Heart Rate (beats per minute)e.g., 70
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Weight (kg)e.g., 53
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Current Medication and Dosing
What ADHD medication are you prescribed?(e.g., Elvanse)
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What is your current daily dose?(e.g., 60mg)
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Are you taking your medication every day as prescribed? (Yes/No) If no, please explain:
How long have you been taking this exact dose without any changes? (e.g., number of weeks) (Please note: To be eligible for shared care, you must have been stable on this dose for at least 8 consecutive weeks.)
Overall, how well is your medication managing your symptoms? (0 = Not at all, 10 = Extremely well)
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Worst
1
2
3
4
5
6
7
8
9
Best
10
1 is Worst, 10 is Best
Please describe any changes you have noticed:
Do you feel your symptoms are stable at this dose? (Yes/No)
Side Effects and Tolerability
Confirm whether you have any side effects.
Are you experiencing any side effects? (Yes/No) If yes give details
Do you feel these side effects are manageable? (Yes/No) If no give details
Other Medications and Health Changes
Tell us about any other treatments or health issues.
Have you started any new medications or supplements? (Yes/No) If yes, please specify:
Have you had any new health problems or significant changes since your last appointment? (Yes/No) If yes, please describe:
Additional Information
Is there anything else you would like us to know before we process your application?
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Consent for shared care
Please confirm you understand and agree to shared care.
I confirm I have been on a stable dose of my medication for at least 8 consecutive weeks.
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I confirm the above statement
I understand that my GP will be asked to take over prescribing under a shared care agreement with ISC-CARE.
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I confirm the above statement
I understand that I will need to attend periodic reviews with ISC-CARE to remain eligible for shared care. These reviews take place every 6 months and currently cost £120 per appointment.
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I confirm the above statement
I confirm that the information I have provided is accurate and complete to the best of my knowledge. I understand that providing false or incomplete information may affect the safety and appropriateness of my treatment and my shared care agreement
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I confirm the above statement
Signature
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My Products
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Shared Care Application
Administrative fee for processing the client's shared care application. (non-refundable)
£50.00
£
50.00
Quantity
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Payment Methods
First Name
Last Name
Credit Card Number
Security Code
Expiration Month
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Expiration Month
Expiration Year
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Submit Application
Submit Application
Should be Empty: