You must have JavaScript enabled to use this form. You can use the form at the bottom of this page to tell us about any health issues which may affect your fitness to practise; if you are a pharmacist or pharmacy technician already registered with us. Please make sure that the information you give on the health declaration form is as accurate and detailed as possible. You will need to let us know: as much detail about your health condition as possible how it affects your ability to practise as a pharmacy professional what treatment or advice you have had, or are getting, for your condition how you are managing the impact of the condition on your ability to work safely You should also include a Health information form filled in by your GP or the doctor who treated you for health issue you are declaring, and an Information from employer form filled in by someone at your workplace. Both documents will automatically download, as you click on the links above. You may also want to include other supporting information, such as an occupational health report. (This is optional.) You will be able to upload all these documents at the end of the web form below. All of the above will help us to make a decision on how to deal with your declaration, and we shall be in touch to let you know about it. Other declarations If you are applying to join our register and have an issue which may affect your fitness to practise, please visit the 'Something to declare' page. If you would like to declare other fitness to practise issues such as a caution, conviction or pending proceedings from another body, please go to: fitness to practise declarations. Remember that, if you have already declared a matter as part of your application to the register or your annual renewal, you do not need to declare it again unless something has changed. Health declaration form Are you: (This is required.) a registered pharmacist or pharmacy technician? an applicant to the GPhC’s register? Registration Number (This is required.) This form is for pharmacists and pharmacy technicians already on our register. If you are applying to join our register and have an issue which may affect your fitness to practise, follow this link to download and fill in the ‘Something to declare’ pdf form. Your details Name (This is required.) Address (This is required.) Email address (This is required.) How would you like us to contact you? (This is required.) mobile land-line phone email post Help What is the best way for us to get in touch with you? Mobile number (This is required.) Land-line phone number (This is required.) Is there a time of day which is best to contact you? Help Please let us know when it would be best for you. For example, ‘before 10am’, ‘after 5pm’ or ‘not on Tuesdays or Wednesdays’. Do you have any specific communication needs? (This is required.) Yes No Please give details. Help Include details of anything we might be able to do that will make it easier for you to talk to us. We will consider all reasonable suggestions. Employer or training provider details Are you currently employed or in training? Yes No Please give us the contact details of your employer or training provider. Name Help If you can, please give us the name of your line manager, or another appropriate person, and their direct contact details. Address Phone Email Do you consider yourself to be disabled? (This is required.) Yes No Please give details of any help you need in your workplace because of your disability, and whether any reasonable adjustment has been or could be made Your health condition Please give details of your health condition, including any diagnosis and symptoms. The date of the diagnosis Day12345678910111213141516171819202122232425262728293031 Day MonthJanFebMarAprMayJunJulAugSepOctNovDec Month Year197319741975197619771978197919801981198219831984198519861987198819891990199119921993199419951996199719981999200020012002200320042005200620072008200920102011201220132014201520162017201820192020202120222023 Year The date of the most recent episode or occurrence Day12345678910111213141516171819202122232425262728293031 Day MonthJanFebMarAprMayJunJulAugSepOctNovDec Month Year197319741975197619771978197919801981198219831984198519861987198819891990199119921993199419951996199719981999200020012002200320042005200620072008200920102011201220132014201520162017201820192020202120222023 Year Details of the advice or treatment you received following the most recent episode or occurrence The effects of your condition How does the health condition affect your ability to do the regular tasks you need to do in your role as a pharmacist or pharmacy technician? Help Give as much detail as you can. Have you tried to get or been given advice from your treating doctor about any risk you pose to members of the public or your colleagues? Yes No Please give details Have you tried to get or been given advice from your treating doctor about any modifications you can make to your practice to reduce the risks? Yes No Please give details Have you been referred to Occupational Health or had any other health assessments? Yes No Please send us any relevant reports you may have received. You can upload copies of these at the end of the form Modifying your practice Have you made any changes to your practice to manage your health condition? Yes No Please give details Have you made any changes to your practice to reduce any risk you pose to members of the public or your colleagues? Yes No Please give details How effective have these changes been? Details of treating doctors Contact details of your GP Name Address Contact details of your consultant (if you have one) Name Address Contact details of your hospital (if relevant) Name Address Leave this field blank Next Page >
