Transcription of Category B Form - Special Access Scheme
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Category B Form - Special Access Scheme
Form no. 2950 (0405)PLEASE USE BLACK PEN, PRINT CLEARLY AND COMPLETE ALL SECTIONSP atient detailsPatient s initials:DOB:MRN:SEX:DiagnosisPrevious SAS No.(if applicable)Clinical justificationfor use of productInclude appraisal ofseriousness of patient'scondition; detailprevious treatments andexpected benefits fromuse of the productProduct detailsAttach efficacy and safety data to support proposed use of the product and details of intended *Complete for medicines *ingredientTrade name/Device nameCompany/supplier(State if imported)Dose form*Route of administration*Dosage*Duration of treatmentDate of medical device procedure/usePrescribing doctor detailsNameInitial SurnameHospitalPostal address (hospital or private).
Title: Category B Form - Special Access Scheme Author: Therapeutic Goods Administration Subject: unapproved therapeutic goods Keywords: special access scheme, medicines, medical devices, australia
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