PV01F05V07
®
PATIENT REGISTRATION FORM
Please print in capitals using a black ballpoint pen.All fields must be completed before form submission. Missing information may result in delays to patient registration.
PatientName: Date of Birth:
PATI
ENT
DET
AIL
S:
Gender: Male Female Proposed Date of Registration:
This patient will be on: Tablets Suspension
Race: Caucasian Asian Afro-Caribbean Mixed Other:
New Patient(never taken clozapine before) History: Restart (Previous brand):
DispensingPharmacy:
Phone: Fax:
Email:
Address: Postcode:
PHA
RM
AC
Y D
ETA
ILS:
Ward Address:
Phone: Fax:
Email:
Inpatient Outpatient
Contact Name(s):
Postcode:WA
RD
D
ETA
ILS:
CONTINUE ON NEXT PAGE
CO
LLEC
TIO
N
LOC
ATIO
N:
Name of Site:
Phone: Fax:
Email:
Contact Name(s):
Address: Postcode:
Clozapine Clinic / Blood Sampling / Collection Location (where the blood is to be taken):
Email:
Name: GMC No.:PRESCRIBERDETAILS:
Please fax this form to the Denzapine Monitoring Team (secure fax) 0333 200 4142
If no, please specify: (an off label agreement will be required)
If yes, please provide details:
(an off label agreement may be required)
DIA
GN
OSI
S:B
asel
ine
Blo
od R
esul
ts:
1. Has the patient ever had an episode of neutropenia? Yes No
2. Does the patient have a confirmed red status in their history? Yes No
3. Does the patient have Benign Ethnic Neutropenia (BEN)? Yes No
4. Does the patient have Treatment Resistant Schizophrenia or Parkinson’s disease? Yes No
5. Are there any contraindications to clozapine in the patient’s history? Yes No
6. Has the patient had impaired bone marrow function? Yes No
7. Is the patient transferring from outside the UK? Yes No
8. Has the patient taken any other antipsychotics? Yes No
If yes, please specify:
Date:
Name: (Please Print)
Signature:
Consultant Psychiatrist / Neurologist/ Responsible Pharmacist / Associate SpecialistI confirm that the patient has been informed that (and has agreed to) his / her data being held on file (whether in electronic or hard copy form). The patient is aware that the data may be used to make decisions about their treatment.
The patient cannot be registered without a valid blood result
NB: The blood sample must have been taken within 10 days of the date of treatment initiation, and ideally less than 7 days.
Date of Baseline Blood Test:
White Blood Cell Count: x 109 /L Neutrophil Count: x 109 /L Platelets: x 109 /L
Other (please specify):
Patient barcode labels to be sent to: Dispensing Pharmacy Blood Sampling / Collection Centre
Additional Information:
PATIENT REGISTRATION FORM Continued
PV01F05V07
®
Please fax this form to the Denzapine Monitoring Team (secure fax) 0333 200 4142