1. Name of the Local Health Board to which the application is made.
2. Type of consent applied for (full or preliminary).
3. Type of application (for example: new inclusion; minor relocation within a Local Health Board’s area; minor relocation between neighbouring Local Health Board areas; temporary relocation; change of ownership).
4. Name and address of applicant.
5. If the applicant is an individual or a partnership carrying on a retail pharmacy business, the applicant’s or each partner’s registration number in the General Pharmaceutical Council register.
6. If the applicant is a body corporate carrying on a retail pharmacy business, the name and registration number of applicant’s superintendent in the General Pharmaceutical Council register.
7. The address of the premises from which the applicant applies to provide pharmaceutical services; or the location of the premises from which the applicant intends to provide pharmaceutical services if the application is for preliminary consent.
8. Whether the applicant is currently in possession of the premises or whether, for example, the premises are under construction or negotiation.
9. The days on which the pharmacy will be open for the provision of pharmaceutical services and the opening hours on those days.
10. Confirmation that all essential services will be provided.
11. Details of directed services that the applicant applies to provide.
12. If the application is to provide services of a different description to those currently provided at the listed premises, details of those services.
13. Where the necessary or expedient test in regulation 9 applies to the determination of an application the applicant must—
(a)provide a written description of the proposed neighbourhood;
(b)provide a map showing the boundaries of the proposed neighbourhood; and
(c)state the reasons why the applicant considers granting the application is necessary or expedient to secure in the neighbourhood the adequate provision, by persons included in a pharmaceutical list, of the services or some of the services specified in the application.
14. Where the prejudice test in regulation 9 applies to the determination of an application, the applicant must state the reasons why he or she considers that granting the application will not prejudice the proper provision of primary medical services, dispensing services or pharmaceutical services in the controlled locality in which the premises specified in the application are situated.
15. Where the applicant applies to relocate (whether within the Local Health Board’s area under regulation 13, between neighbouring Local Health Board areas under regulation 14 or on a temporary basis under regulation 15) the applicant must provide details of the proposed relocation including the address of the applicant’s existing listed premises.
16. Where the application involves a minor relocation between neighbouring Local Health Board areas under regulation 14 the applicant must state—
(a)the name of the Local Health Board where the existing premises are located;
(b)that the applicant consents to the removal of his or her name from the pharmaceutical list maintained by the Local Health Board in whose area the existing premises are located and in respect of those existing listed premises with effect from the date on which the provision of pharmaceutical services from the new premises will commence.
17. The applicant must provide details of whether—
(a)for the patients who are accustomed to accessing pharmaceutical services at the existing premises, the location of the new premises is significantly less accessible;
(b)the same pharmaceutical services will be provided at the new premises as are provided at the listed premises; and
(c)the provision of pharmaceutical services will be continuous or interrupted and the reasons for any interruption.
18. If the application is for a temporary relocation, the applicant must state the circumstances that require a temporary relocation.
19. Name of the person included in the pharmaceutical list currently providing pharmaceutical services from the premises.
20. The applicant must provide details of whether—
(a)the same pharmaceutical services will continue to be provided from the premises; and
(b)the provision of pharmaceutical services will be continuous or interrupted and the reasons for any interruption.
21. The applicant must give an undertaking that if the application is granted the applicant will provide the services at the premises in respect of which the application is granted in accordance with the terms of service.