Please complete all form fields before submission of application.

Missing information may result in delays to patient transfer – to be used in conjunction with Patient Bulk Transfer Form (Brand to Denzapine) – Patient and Pharmacy Details (PV01F48).

The transferring patients have been advised that their data will be transferred to an alternative clozapine supplier.

Note: This is required as per data protection requirement not patient consent only. If details not provided this may prevent the transfer taking place.

Transferring To:

Name of Prescriber: See Attached Spreadsheet

Proposed Date of Transfer: See Attached Spreadsheet

Please download the SOP FORM PV01F48 V04 - Excel document_VT_Final - Protected.xlsx and enter the bulk patient information. Fields required are Patient Name, DOB, Gender, CPMS/ZTAS Number, Current Monitoring Frequency, Consultant Psychiatrist / Neurologist (Full Name), Pharmacy Site (Full Address), Collection Centre / Ward (Full Address), Diagnosis? TRS, Parkinsons or Other (if other please state), BEN (Benign Ethnic Neutropenia)? Y/N, Proposed Date of Transfer,Blood Barcodes to be sent to? (Collection centre or Pharmacy). Once the spreadsheet has been completed please browse to the spreadsheet using the browse button and upload the spreadsheet to complete the form and electronically sign.

Additional Information:

Consultant Psychiatrist / Neurologist / Associate Specialist/ Responsible pharmacist

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.

Bulk Patient Spreadsheet (xlsx)