All fields must be completed before form submission

Missing information may lead to delays in processing the application.

NB: The blood sample must have been taken within 10 days of the date of treatment initiation, and ideally less than 7 days.
Additional Information:
The patient cannot be registered without a valid blood result
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.