Statement for Requests for Shared Care Agreements for Historic Patients

SCA’s are currently listed alphabetically by drug name (or disease). Where a drug doesn’t have it’s own specific request form please use this one Shared Care Request Form. This generic shared care request form  is based on the national SCA forms and will be in use from the 3rd January 2023.

A programme of review of these shared care agreement documents is currently being undertaken. These are the current shared care agreements. If there are any concerns please contact [email protected]. Please do not send patient identifiable information as email may be unsecure.

New Request Form National Format

ADHD (paediatric)    New Request Form National Format

Agomelatine  New Request Form National Format

Aliskiren

Allergen Specific Sublingual Immunotherapy (Acarizax, Grazax and Itulazax) in adults   Request form

Allergen Specific Sublingual Immunotherapy (Acarizax  And Grazax ) in Paediatrics

Amiodarone (adults)

Apomorphine

Atomoxetine (adults)  New Request Form National Format

Atomoxetine (paediatric)

Azathioprine (dermatology)   New Request Form National Format 

Azathioprine (adult gastroenterology)

Azathioprine (paediatric gastroenterology)

Azathioprine neurology    New Request Form National Format

Azathioprine (rheumatology)      New Request Forms National Format

Ciclosporin (dermatology) New Request Forms National Format

Colistin (Historical Cystic Fibrosis Patients Only)

Dantrolene

Dapsone (Dermatology)

Denosumab (Prolia) for osteoporosis   New Request Forms National Format

Denosumab (Xgeva)  for prevention of skeletal events with bone metastases

Dexamfetamine (adults)  New Request Form National Format

Dexamfetamine (paediatric) 

Guanfacine (adult)  New Request Form National Format

Guanfacine (paediatric)

Hydroxycarbamide

Leflunomide     New Request form National Format

Lisdexamfetamine (adults)   New Request Form National Format

Lisdexamfetamine (paediatric) 

Lithium     Request form  New Request Form National Format

Mercaptopurine (paediatric gastroenterology)

Mercaptopurine (adult gastroenterology)

Methotrexate oral (rheum/Derm/Gastro)   New Request Form National Format

Methylphenidate (adults)  New Request Form National Format

Methylphenidate (paediatric) 

Mycophenolate Mofetil Autoimmune conditions  

Mycophenolate Mofetil Request form Dermatology    New Request Form National Format

Mycophenolate Mofetil Request form Neurology      New Request Form National Format

Mycophenolate Mofetil Request form Respiratory    New Request Form National Format

Mycophenolate (renal transplant)

Paediatric Cardiology Medications

Penicillamine (rheumatology)     New Request Form National Format

Riluzole

Sulfasalazine oral (rheumatology)     New Request Form National Format

Sulfasalazine oral and rectal (gastroenterology)

Tacrolimus for Historic Renal Transplant Patients

Testosterone (adults)

Testosterone (paediatric)

Venlafaxine (high dose)   New Request Form National Format