We ask all community pharmacies in Somerset to complete this form.  It will allow us to develop a Service Database detailing where patients can access commissioned services in Somerset. This can then be used by pharmacies to signpost patients to the nearest pharmacy able to offer that service.  By submitting this form, you consent to the LPC using the information submitted for this purpose.

Pharmacy Name

Pharmacy Address

Services you provide and have recently signed a SLA with the Area Team/Somerset County Council to cover the 2014/2015 financial year

Emergency Hormonal Contraception

Minor Ailments

Supervised Consumption

Smoking Cessation

Needle Exchange

Palliative Care

Chlamydia Screening Bins

Please only tick boxes for services you currently provide and/or have signed a SLA with the BNSSSG Area Team or Somerset County Council to say you will provide this service for the 2014/2015 financial year. DO NOT tick boxes for services not provided at your pharmacy, or those that you wish to provide in the future.

Name of person completing form

Role of person completing form