prescription form

TEFF (BROWN & WHITE) FLOURS NOW AVAILABLE ON PRESCRIPTION!

Please download this form to use when ordering Pure products on prescription. You can also download a full price list here.

Take this form to your GP now!

Date:

Dear Doctor ……………………………

Please amend my prescription to include the following ‘Pure Products’ which have ACBS approval, please see over for further information of PPA listings should you experience any difficulty tracing the relevant approval for these products.

PRODUCT	WEIGHT	PIP CODE	NO SACHETS/CASES REQUIRED
Pure Xanthan	100g	282 - 8572
Pure Gluten-Free Blended Flour	1kg	282 - 8580
Pure White Rice Flour	500g	325 - 7904
Pure Brown Rice Flour	500g	325 - 7912
Pure Potato Starch	500g	325 - 7920
Pure Tapioca Starch	500g	325 - 7946
Pure White Teff flour	1kg	343 - 1483
Pure White Teff flour	3 x 1kg	343 - 1491
Pure Brown Teff flour	1kg	343 - 1467
Pure Brown Teff flour	3 x 1kg	343 - 1475

Thank you,

_______________________ (Signature)

Name: ______________________________________

Address: ______________________________________

______________________________________

Post Code: _________________ Tel: ________________

Dear Doctor: For more information about ‘Pure Products’ please telephone our office or visit the website.

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Detach This Portion And Take It To Your Pharmacist With Your New Prescription:

The ‘Pure Products’ included in this prescription are ACBS approved and available direct from the manufacturer or via your pharmaceutical supplier as a “special” order:

Innovative Solutions (UK) Ltd

The Mayfield Centre

Mayfield St., Rochdale

OL16 2UZ

Phone/Fax: 01706 746713

Email: info@innovative-solutions.org.uk

Please be sure to tell us the invoice address should it differ from the delivery address.

It has been noted that occasional GP surgeries have had difficulty prescribing the products listed, we hope that this may help.

Drug Tariff from Borderline substance list

(http://www.epact.ppa.nhs.uk/ppa/edt_intro.htm)

Innovative Solutions brown rice flour

Innovative Solutions potato flour

Innovative Solutions pure gluten-free blended flour

Innovative Solutions pure xanthan gum

Innovative Solutions tapioca flour

Innovative Solutions white rice flour

Dm&d Product list (http://www.dmd.nhs.uk/)

Innovative Solutions gluten free brown rice flour

Innovative Solutions gluten free potato flour

Innovative Solutions gluten free tapioca flour

Innovative Solutions gluten free white rice flour

Innovative Solutions pure gluten free blended flour

Innovative Solutions pure xanthan gum

Innovative Solutions gluten free brown Teff flour
Innovative Solutions gluten free white Teff flour

Innovative Solutions UK Ltd.

Tel/Fax: 01706 746713 or Tel: 01706 341700