All fields must be completed before form submission

Missing information may lead to delays in processing the application.

By signing this form, I confirm that the patient has been notified that their data will be transferred to an

alternative Clozapine supplier.

Consultant Psychiatrist / Neurologist / Responsible Pharmacist/ Associate Specialist
I 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.