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1. Name of the Primary Care Trust to which the application is made.
The type of consent applied for (preliminary or full).
The type of application (for example, application for change of premises, change of ownership etc.).
2. Name and address of applicant.
The applicant’s Royal Pharmaceutical Society of Great Britain registration number.
Where the applicant is a corporate body, name and registration number of superintendent (where known).
Where the applicant is a temporary chemist, the name of the suspended chemist.
3. Name and address of premises or where seeking preliminary consent, relevant location of premises.
Whether the applicant is currently in possession of the premises.
Proposed hours during which the applicant will be obliged to remain open by virtue of paragraph 22(1) of Schedule 1 or paragraph 10(1) of Schedule 3, and days on which and times at which pharmaceutical services will be provided if the application is granted.
Proposed opening hours, if any, during which the applicant proposes to open in addition to those during which he is obliged to remain open and days on which and times at which pharmaceutical services will be provided if the application is granted in relation to those additional hours.
4. Confirmation that all essential services will be provided.
If directed services are to be provided—
details of the services to be provided;
confirmation that the applicant is accredited to provide such directed services where accreditation is a requirement for the provision of those services;
confirmation that the premises are accredited where accreditation is a requirement for the provision of those services; and
floor plan showing consultation area where the applicant proposes to offer directed services (where available and relevant).
5. Where regulation 12 applies, reasons why the applicant considers the granting of the application is necessary or desirable in order to secure the adequate provision of pharmaceutical services in that neighbourhood.
Where an applicant does not wish to rely on an exemption under regulation 13, a statement that the applicant does not want the exemptions to apply.
Where regulation 13 applies and the applicant does seek to rely on an exemption, which exemption is applicable and—
where regulation 13(1)(a) applies—
the name of the approved retail area,
confirmation that the retail area is approved by the Secretary of State under regulation 15(1), and
details of the directed services the applicant will undertake;
where regulation 13(1)(b) applies—
details of how the pharmacy will be staffed during its opening hours, and
details of the directed services the applicant will undertake;
where regulation 13(1)(c) applies—
the names of the persons carrying on business as a consortium,
an outline of its management and equity structure,
the articles of association of the consortium,
confirmation that the one-stop primary care centre is part of the Primary Care Trust’s strategic service development plan or equivalent plan and was included in that plan for the first time on or after 1st April 2005,
the number of patients on the patient list of the provider of primary medical services and the name and address of that provider,
details of the health and social services to be provided from the one-stop primary care centre, and
details of the directed services the applicant will undertake; or
where regulation 13(1)(d) applies, details of how the applicant will provide the essential services.
6. Where the application is made under regulation 5(1)(c), name of the Primary Care Trust where the existing premises are located and the consent required by regulation 7(1)(b).
Reasons for the relocation.
Where the application is in relation to a minor relocation, information as to why the relocation is minor and the distance of the new premises from the old premises by the nearest practicable route by foot where this is less than 500 metres.
Whether the provision of services will be continuous or interrupted, together with the reasons for any interruption.
7. Details of additional services the applicant proposes to provide.
If directed services are to be provided—
details of the services to be provided;
confirmation that the applicant is accredited to provide such directed services where accreditation is a requirement for the provision of those services;
confirmation that the premises are accredited where accreditation is a requirement for the provision of those services; and
floor plan showing consultation area where the applicant proposes to offer directed services (where available and relevant).
8. Name of previous owner.
Whether the provision of services will be continuous or interrupted, together with the reasons for any interruption.
Whether the same services will be provided.
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