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Unlisted drug and chemical request form

Please fill in the name of any drugs which you are unable to code through the regular books and submit this form to the HIPE Unit in the ESRI, and codes will be supplied as soon as possible.

Enter Details
Coder's Name:*
Hospital Number:*
Drug Details:*
All * fields are required.

The form can be downloaded, by clicking the link below and completed and returned by post.