Pharmaceutical Company Representative Visit Request Form

This form is for pharmaceutical industry representatives wishing to request an appointment with the NECS Medicines Optimisation Team.

Requests for appointments will be considered on an individual basis and representatives will be contacted if an appointment is to be made (one product per appointment, maximum visit 30 minutes).  A request for an appointment will not guarantee that an appointment will be arranged.

The requests will be triaged by the MO team to determine whether the request to discuss a particular product or initiative will meet the priorities of the CCG or would benefit the work scheduled in the prescribing committees within the localities.

A pharmaceutical representative will not normally be given another appointment to discuss the same product(s) within a 6 month period unless agreed at a previous meeting or new (and significant) information has become available. This will facilitate equality of access for all pharmaceutical companies within limited resources.  The number of representatives expected to attend the meeting must be stated on the form below.  Additional representatives who arrive for allocated appointments may be asked to leave or the appointment may be cancelled

Pharmaceutical company:

Representative’s name(s):

Number of representatives expected to attend meeting:

Date of request:

Contact telephone number:

Contact email address:

Product name (generic and proprietary):

New product:

Existing product:

Is the product subject to a Rebate or access scheme?
YesNo

If yes, has the rebate been discussed with David Cook, regional Procurement Pharmacist? (North East & Cumbria Only)
YesNo

If yes, where is it approved?

Is the product approved for use in the NECS area?
YesNo

Indication for use:

Reason for appointment request:

Appointment request to see: (Select CCG)
CumbriaDarlingtonEast Riding of YorkshireHartlepool and StocktonHullNorth East LincolnshireNorth LincolnshireNorthumberlandNorth TynesideSouth TeesSouth Tyneside

Please indicate information supplied: (wherever possible please provide e-copies of documents presented)
SPCPublished comparative trial dataComparative costsPromotional material

Any other supporting information:

Human verification
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Supporting information should be returned either by email to NECSU.medicinesnewburn@nhs.net

Posted to: Medicines Optimisation North of England Commissioning Support, Riverside House, Goldcrest Way, Newburn Riverside (Business Park), Newcastle upon Tyne, NE15 8NY

Faxed to: (0191) 2172506