All fields must be completed before form submission

Missing information may lead to delays in processing the application.

User Access Level (Select ONE level only)

In signing this document you agree to abide by the conditions outlined below:

  • You will not use any of the information contained on the Denzapine Monitoring System database (“DMS”) for any purpose other than to monitor the suitability of patients for treatment with Denzapine.
  • If you are granted Read/Write access you will be responsible for the accuracy of information that you add to DMS.
  • When access is no longer required you will inform the Denzapine Monitoring Team and your user ID will be disabled.
  • Your User ID may only be used by you, the registered user, and you will not give your User ID or password to anyone else.
  • You will be responsible for any malicious software, viruses or other destructive computer programs downloaded from your computer/server onto DMS and you will ensure your computer systems have suitable and up-to-date anti-virus and security software.
  • If allowing nurse access, you are giving your consent for this nurse to have access to the DMS database for all patients associated with the above pharmacy(ies). You recognise that this may give access to more than just their own direct patient caseload. Please note that the Denzapine Monitoring Services reserves the right to review any request for read/write access. Each case will be considered on its own merits.

Britannia may disable your User ID if you fail to comply with, or if Britannia has reasonable grounds to believe you have failed to comply with, any of the above conditions. Britannia reserves the right to change these conditions upon reasonable notice. Your User ID registration confers no ownership rights over DMS which remains the sole property of Britannia Pharmaceuticals Ltd. Your personal data will only be used by us in accordance with Britannia’s Privacy Policy which can be found at

www.britannia-pharm.co.uk/privacy-policy.html

Responsible Pharmacist (This must be signed by the Responsible Pharmacist or equivalent, not to be signed by the individual requesting access)