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