Greater Manchester Healthy Living Pharmacy

Pharmacy Information Survey

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* 1. Contact Information

GPhC registered first name:

GPhC registered surname:

Pharmacy Name:

Pharmacy Address:

Post Code:

ODS code:

GPhC number:

Email Address:

Contact Number:

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* 2. What is your CCG locality area?

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* 3. Are you a HLP pharmacy?

Yes

No

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* 4. If no, would you be interested in becoming an HLP pharmacy?

Yes

No

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* 5. Have you received HLP accreditation?

Yes

No

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* 6. Have you got a HLP Champion? If yes please provide details:

Full Name

Role

Do they still work at the pharmacy?

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* 7. Has your pharmacist attended leadership training? If yes please provide details:

Full Name

When did they receive this training?

Do they still work at the pharmacy?

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* 8. Have you got a pharmacist or pharmacy member trained as a Dementia friend? If yes please provide details:

Full Name

Role

Do they still work at the Pharmacy?