S T

Surgery and Theatres

P G

Pharmacists Group
   
Application Form

Please complete this form if you wish to join the Surgery and Theatres Pharmacists Group. Applicants should be members of the UKCPA. However, non-members may apply to join the group and full UKCPA membership form will be sent out.

Membership of the Surgery and Theatres Pharmacists Group is free. Membership will only be activated after payment of the UKCPA membership fee.

Details of members will be published in the group's Directory . The Directory is sent to all members of the group. If you do not wish to have your details published in the Directory, please tick the relevant box later.

This application form is divided into the following sections:

Fill out the information in each section as requested. You will receive a confirmation message from us shortly.

Contact information

Please complete all of these fields. Do not enter your home address, even if you receive all your UKCPA mailings at that address.

  1. What is your UKCPA membership number. (It is on the address label of all your UKCPA correspondence.)?

  2. What is your work mailing address? 
    Name     
    Job title
Dept.    
Hospital 
Address  
City     
Country  
Post Code
    Tel. no. 
Fax. no. 
e-mail
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Main area of activity

Please mark the main area of practice that you work in.

  1. Accident & Emergency
  2. Breast surgery
  3. Burns
  4. Cardiac surgery
  5. Cardiac transplant
  6. Colorectal surgery
  7. Day case surgery
  8. Dental
  9. Ear, Nose and Throat
  10. Gynaecology
  11. High Dependency Unit
  12. Intensive Care Unit
  13. Liver transplant
  14. Maxillofacial surgery
  15. Neurosurgery
  16. Ophthalmology
  17. Orthopaedics
  18. Paediatric surgery
  19. Pancreatobiliary surgery
  20. Plastic surgery
  21. Pre-admission clinics
  22. Radiology
  23. Renal transplant
  24. Spinal injuries
  25. Theatres
  26. Thoracic surgery
  27. Upper gastrointestinal surgery
  28. Urology
  29. Vascular surgery
  30. Other. Please state:

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Specialist knowledge or files

Please tick any box in for any area in which you consider yourself an expert or have access to specialist files. If you tick any box you should be willing to accept calls from other pharmacists for advice.

Type of surgery

  1. Accident & Emergency
  2. Breast surgery
  3. Burns
  4. Cardiac surgery
  5. Cardiac transplant
  6. Colorectal surgery
  7. Day case surgery
  8. Dental
  9. Ear, Nose and Throat
  10. Gynaecology
  11. High Dependency Unit
  12. Intensive Care Unit
  13. Liver transplant
  14. Maxillofacial surgery
  15. Neurosurgery
  16. Ophthalmology
  17. Orthopaedics
  18. Paediatric surgery
  19. Pancreatobiliary surgery
  20. Plastic surgery
  21. Pre-admission clinics
  22. Radiology
  23. Renal transplant
  24. Spinal injuries
  25. Theatres
  26. Thoracic surgery
  27. Upper gastrointestinal surgery
  28. Urology
  29. Vascular surgery
  30. Other. Please state:

General Knowledge.

  1. Antibiotic prophylaxis
  2. Antibiotic treatment
  3. Chronic pain
  4. Day case analgesia
  5. Discharge planning
  6. Epidurals
  7. Fluid balance
  8. Home TPN
  9. Inflammatory bowel disease
  10. Intravenous therapy
  11. Long term medication & surgery
  12. Palliative care
  13. Patient controlled analgesia
  14. Pharmacists in the operating theatre
  15. Post operative complications
  16. Post operative nausea & vomiting
  17. Post operative pain control
  18. Pre-admission clinics
  19. Satellite pharmacy
  20. Self medication
  21. Splenectomy prophylaxis
  22. Surgical protocols
  23. Surgical audit
  24. Teaching pharmaceutical care in surgery
  25. Thromboembolic prophylaxis
  26. Thrombolysis in surgical patients
  27. Total parenteral nutrition
  28. Wound management
  29. Other. Please state:
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FORM SUBMISSION

Thank you for taking the time to complete the application form. Please print it out and send it to

Philip Howard
Pharmacy
Leeds General Infirmary
Great George Street
LEEDS LS1 3EX
England

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Philip Howard
Copyright © 1998 UKCPA All rights reserved.
Revised: May 11, 1999.