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This document is for community pharmacy to record any provider/organisations that has either put undue pressure on to a pharmacy to provide an MCA to a patient or has directly told the patient that they require an MCA.

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* 1. Pharmacy details

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* 2. Please identify the provider/organisation that has either put undue pressure on you to provide an MCA to a patient or has directly told the patient that they require an MCA.

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* 3. Please enter the name of the provider/organisation.

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* 4. Please enter the date this occurred.

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* 5. Please identify how many patients this has affected:

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* 6. Please give any further details.

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