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 therapy.

Please complete all fields before submission of this form.

Missing information may lead to delays in processing the application.

If not registered on the GMC Specialist Register, please confirm below that you are the most appropriate healthcare

professional to be registered as the responsible consultant for clozapine patients.

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 SmPC.