Enquiries Form

Healthcare professionals may use this form to submit enquiries to the East Anglia Medicines Information Service.

Healthcare professionals may use this form to submit enquiries to the East Anglia Medicines Information Service.

Section 1
Contact details
Name*
First Last
Job role*
Organisation (and department where applicable)*
How would you like to receive your reply?*
- E-mail
- Telephone
Please enter your email address or telephone number*
Does your question involve a specific patient?
- Yes
- No
If 'Yes' please proceed to continue to Section 2. If 'No' please proceed to Section 3.
Section 2
Patient details
Patient's initials
NHS number (if known)
Hospital number (Ipswich Hospital only)
Date of birth
Date Format: DD slash MM slash YYYY
Patient identifiers not known
Section 3
Question details
When do you need an answer?
Date Format: DD slash MM slash YYYY

Please note you may be contacted if we cannot meet this deadline. Please give a specific date - do not use ASAP.
Your question:
By submitting this form, you agree that the web server will submit details of pages I have visited on this web site.*
- Tick here

Section 1