Alcohol Dependency > Alcohol Treatment Request Alcohol Treatment Request Eligibility to ContinueThis form is for patients who have already completed their consultation and received a valid prescription. It does not replace a clinical consultation.Have you completed your consultation with Sinclair Method UK?(Required) Yes, I have completed a consultation No, I need to complete a consultation ✕ Warning — Cannot Continue Valid Prescription Required This form is provided by Sinclair Method UK. They complete the clinical assessment and prescribing decision. Complete Clinical Assessment Do you have a valid prescription?(Required) Yes No ✕ Warning — Cannot Continue Valid Prescription Required A valid prescription from an authorised prescriber is required before treatment can be dispensed. Complete Clinical Assessment Patient DetailsFull Name(Required)Enter your full legal name.Date of Birth(Required) DD slash MM slash YYYY Your date of birth is required to verify you are over 18 and eligible for treatment.Email Address(Required) We will use this email address to send consultation updates and treatment information.Phone Number(Required)A pharmacist may contact you if further clinical review is required.Address(Required) Street Address Address Line 2 City Post Code Essential Safety ChecksDo you have any medication allergies?(Required) Yes No List your allergies(Required)List any medication allergies.Are you taking any other medication?(Required) Yes No List current medication(Required)Include prescription, over-the-counter, and supplements.Has your health changed since your consultation?(Required) Yes No i Please Note Health Changes Require Review Changes in your health may affect suitability. The pharmacist will review your request before approval. Have you had a recent liver function test?(Required) Yes No This may be required before treatment can be supplied. ! Warning — Please Read Recent Liver Function Test May Be Required A recent liver function test may be required. The pharmacist will review your request before approval. Customer NotesAdditional NotesOptional – include delivery preferences or any important information.GP Details and ConsentGP Practice NameEnter the name of your GP surgery if known.GP Practice PostcodeEnter the postcode of your GP surgery if known.Consent to contact my GP if needed(Required) Yes No I consent to the pharmacy contacting my GP practice if needed to support my treatment review. ! Warning — Please Read GP notification recommended We recommend informing your GP for continuity of care. A clinician may discuss this with you. DeclarationsPrescription Confirmation(Required) I confirm I have a valid prescriptionI confirm that I have a valid prescription and authorise the pharmacy to review and process it.Information Accuracy(Required) I confirm my information is accuratePlease ensure all details are correct before submitting.Alcohol Dependency Treatment Review Consent(Required) I consent to this treatment reviewI consent to the pharmacy reviewing my information to confirm that my prescribed treatment remains appropriate to supply.Privacy Policy(Required) I agree to the Privacy PolicyPlease review how we collect, use and protect your personal data.CAPTCHA What to expect Complete your consultation with our partner prescribing clinic. If approved, your treatment can be supplied through our pharmacy.Clinical review by prescribing partnerOutcome sent by emailPayment and supply arranged if approved Next steps 1Complete the alcohol support consultation 2Your assessment is reviewed clinically 3You receive the outcome by email 4Payment and supply arranged if approved