Form

Form MD36

Application for a licence to prescribe, administer, supply or authorise administration or supply of cocaine, diamorphine or dipipanone.

• From: Home Office
• Published: 21 March 2012
• Last updated: 13 March 2023
  Show all updates

  1. 13 March 2023

     Scanned signatures can now be uploaded to the form.

  2. 22 November 2022

     Updated form published.

  3. 30 May 2022

     Updated form MD36.

  4. 18 June 2018

     Updated application form.

  5. 29 January 2018

     Updated MD36 application form.

  6. 21 March 2012

     First published.

Documents

Form MD36

MS Word Document, 54.4 KB

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Details

The application form is available to download.

We are aware this publication may have accessibility issues. We are reviewing it so that we can fix these. Read more about our accessible documents policy.

If you need help in the meantime please email either:

• doctor.licensing@dhsc.gov.uk in England
• pschiefmedicalofficer@gov.wales in Wales