Please Select the Associated PCN:

Harlow North

Harlow South

South Uttlesford

North Uttlesford

Loughton, Buckhurst Hill and Chigwell

Epping Forest North

Please Select the Type of Support Service(s) for Activation:

DOAC Protect

Hypertension Protect

Diabetes Protect

Proposed start date:

This month

Next month

Within 3 months

Within 6 months

Level of Support Wanted

Training for Own Team Only (Enables identification and automated patient engagement)

Use of PPF Pharmacist without GP Support (Enables remote patient reviews but no changes to medication)

Use of PPF Pharmacist with GP Support (Enables remote patient reviews and medication optimisations)

Key Contact 1 - Practice Admin Lead for this Programme

First Name

Last Name

Key Contact 2 - Practice Clinical Lead for this Programme

First Name

Last Name