Health declarations

You can use this form if you are a pharmacist or pharmacy technician already registered with us to tell us about any health issues which may affect your fitness to practise.

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.

If you are applying to join our register and have an issue which may affect your fitness to practise, contact our registration department on info@pharmacyregulation.org.

Please make sure that the information you give on this form is as accurate and detailed as possible.

What you 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 doctor who has treated you and an Information from employer form filled in by someone at your workplace. You will be able to upload these at the end of the form.

You may also want to include other supporting information, such as an occupational health report.

This information will help us to make a decision on how to deal with your declaration.

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

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, contact our registration department on info@pharmacyregulation.org or 020 3713 8000.
Your details
Help
What is the best way for us to get in touch with 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’.
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
Please give us the contact details of your employer or training provider.
Help
If you can, please give us the name of your line manager, or another appropriate person, and their direct contact details.
Your health condition
The effects of your condition
Help
Give as much detail as you can.
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
Details of treating doctors

Contact details of your GP

Contact details of your consultant (if you have one)

Contact details of your hospital (if relevant)