Borderline Medicine Advice Form

Medicines Borderline Advice Form

Please use this form to request advice from the Medicines Borderline Section on a medicinal product only.

(If you require advice regarding a proposed medical device, please e-mail clare.headley@mhra.gsi.gov.uk)

Your request advice will be acknowledged and a full reply will be sent in due course

Please provide as much detail as possible. Fields indicated with a * are mandatory.

Contact details


Contact name*			Title*
Correspondence address*
Postcode*
Telephone number
E-mail address
Confirm e-mail address

Company Details


Reference number (if any)
Company name*
Company address*

About the Product Note: Opinion will only be based on the information provided


Product name*
Product form* E.g tablet, capsule, cream etc.

Please include details of the amount of each ingredient. If the ingredient is herbal please give the botanical name and the part of the plant being used.


Active Ingredients:*
Excipients:*
Purpose of product:*
Product's mode of action:

For advice regarding a proposed medical device, please e-mail clare.headley@mhra.gsi.gov.uk

Claims / wording used to promote the product

Please give the actual text or wording used to promote the product:*


Attach File(click the icon to browse for a file)
Note: All promotional material relating to the product must be attached

Note - Opinion will only be based on the information provided.

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