Transcription of CLOZAPINE PRESCRIBER REGISTRATION FORM - …
1 CLOZAPINE PRESCRIBER REGISTRATION FORMF irst Name:Surname:Phone: Mobile Phone Number / Out of Hours contact:Fax:Email:GMC Number:Consultant Psychiatrist/ Neurologist/ Associate SpecialistDate:Name: (Please Print)Signature:In signing this form I confirm that I am medically qualified to prescribe Denzapine and am aware to all procedures relating to Denzapine treatment. I will also adhere to the Denzapine Monitoring Service (DMS) practices and Denzapine :Postcode:I, the undersigned hereby agree, To participate in the distribution of and treatment with Denzapine within the Denzapine Monitoring System (DMS). Abide by the obligations set out in the Summary of Product Characteristics (SmPC) for all patients undergoing Denzapine print in capitals using a black ballpoint complete all fields before submission of this form . Missing information may lead to delays in processing the fax this form to the Denzapine Monitoring Team (secure fax) 0333 200 4142
