PRESCRIPTION REQUEST FOR GLUTEN-FREE FOODS
This list is the approved list of gluten-free foods supported for funding.
Patient Name:_____________________________________________________
Patient’s address and postcode:_______________________________________
Usual GP:_________________________________________________________
Please indicate the quantity required for each item up to a maximum of 8 items per month.
*Fresh bread is supplied in a box of 8, therefore only one type of fresh bread can be
ordered per month and no other item on the list as this will constitute the 8 items per
month. G/F – gluten free and W/F – wheat free
Juvela Fresh White Sliced Loaf 400g (8 loaves of bread)
Juvela Fresh Fibre Sliced Loaf 400g (8 loaves of bread)
Juvela Fresh Fibre Rolls (8 packs of 5 rolls)
Juvela Fresh White Rolls (8 packs of 5 rolls)
Juvela Fresh Mixed Fibre Loaves and Rolls (4x400g + 4x5 rolls)
Juvela Fresh Mixed White Loaves and Rolls (4x400g + 4x5 rolls)
Glutafin Select Fresh Brown Bread 400g (8 loaves of bread)
Glutafin Select Fresh White Bread 400g (8 loaves of bread)
Genius_G/F Bread Brown sliced (8 loaves of bread)
Genius_G/F Bread White sliced (8 loaves of bread)
Genius_G/F W/F Brown Bread (8 loaves of bread)
Genius_G/F W/F White Bread (8 loaves of bread)
Warburtons G/F W/F White Sliced Bread 400g (8 loaves of bread)
Warburtons G/F W/F Brown Sliced Bread 400g (8 loaves of bread)
Warburtons G/F W/F Brown Rolls (3 pack of sub rolls) 220g (8 packs of 3 rolls)
Warburtons G/F W/F White Rolls (3 pack of sub rolls) 220g (8 packs of 3 rolls)
Long Life Bread products that are available:
Ener-G gluten-free brown rice bread 474g
Ener-G gluten-free tapioca bread sliced 480g
Ener-G gluten-free white rice bread sliced 456g
Glutafin gluten-free wheat-free fibre loaf sliced 400g
Glutafin gluten-free wheat-free white loaf sliced 400g
**Glutafin Select gluten-free fibre loaf sliced 400g
**Glutafin Select gluten-free seeded loaf sliced 400g
**Glutafin Select gluten-free white loaf sliced 400g
Juvela gluten-free fibre loaf sliced 400g
Juvela gluten-free fibre loaf unsliced 400g
Juvela gluten-free white loaf sliced 400g
Juvela gluten-free loaf white unsliced 400g
Quantity
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
**– these Glutafin Select long life products have been reformulated and no longer need to be refreshed.
Flour products that are available:
Innovative Solutions Pure White Rice Flour
Innovative Solutions Pure Brown Rice Flour
Innovative Solutions Pure Gluten-Free Blended Flour
Orgran self-raising flour
Bread Mix that is available:
Orgran Bread Mix
Please take to your GP practice where a prescription will be generated.
22/03/13
VERSION 4