Clozapine Prescriber

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.

First Name

Surname Name

Address

Address2

Postcode

Phone

Fax

Mobile Phone Number / Out of Hours Contact

GMC Number

Registered on the GMC Specialist Register: Yes No

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.

By clicking the submit button above the form will be sent to you via the Britannia eSign to the email you have supplied above.

The The Clozapine Prescriber Form has validation errors. Fields requiring attention are highlighted in red above.