Healthcare Professional Agreement to Supply Ulipristal Acetate - Patient Group Direction Form

Sep 19, 2026

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This document serves as a formal agreement form for healthcare professionals authorized to supply Ulipristal Acetate (UPA-EC) under the Patient Group Direction (PGD) framework. It covers multiple NHS regions, including Grampian, Highland, Orkney, Shetland, Tayside, and Western Isles. By signing this agreement, the professional confirms they have completed the required specialized training and pledge to operate strictly within their professional competence and the specific guidelines provided by the PGD for emergency contraception services. This template ensures that medical staff are legally and professionally aligned with institutional standards before administering specified medications to patients. It requires detailed entry of the practitioner's name, area of practice, signature, date, professional designation, and registration PIN to ensure full accountability and compliance with health board regulations across the specified Scottish health service areas.

LanguageEnglish

CategoryForms

FormatPDF

Pages1

AccessFree to download

Healthcare Professional Agreement to Supply Medicine(s) Under Patient Group Direction

Professional Commitment and Authorization

FAQs

What is the purpose of this form?

This form is a formal agreement for healthcare professionals to confirm their authorization and competence to supply Ulipristal Acetate for emergency contraception under a specific Patient Group Direction (PGD).

Which health regions does this agreement cover?

The agreement applies to approved healthcare professionals working within the NHS regions of Grampian, Highland, Orkney, Shetland, Tayside, and the Western Isles.

What are the responsibilities of the signatory?

By signing, the professional confirms they have completed mandatory training, agree to remain within their professional competence, and adhere to all recommendations outlined in the Patient Group Direction.

Sep 19, 2026

Upload by Hazel