Consultant Psychiatrist Data Form

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CONSULTANT PSYCHIATRIST DATA FORM
This form is used to register as a Consultant, Associate Specialist or Specialty Doctor in the field of Psychiatry (or other relevant* therapeutic area) with the Zaponex Treatment Access System (ZTAS®). Please complete all sections.
We will use the information provided on this form in accordance with the terms explained in the ZTAS privacy notice which is available from the ZTAS website www.ztas.co.uk.

Consultant Psychiatrist Details
* Or other specialist relevant in the context of Zaponex® (clozapine) treatment indications, as per SPC.
Title ProfDr GMC
Name
Grade ConsultantAssociate SpecialistSpeciality Doctor
Speciality
Emergency telephone number Office telephone
Personal email
Example: john.smith@nhs.net.Please do not use group email addresses or gmail/yahoo, etc.
 
Notification standard
ZTAS reminders, warnings and alerts will be sent to your personal email address as above.
*Registration of a group email address requires a Data Sharing Form to be completed and returned
 
Primary Address
Facility
Address
Town/City
Postcode
Adverse event reporting
The ZTAS routinely monitors blood results for abnormalities in WBC, Neutrophils, Eosinophils and Platelets.Abnormalities in these parameters(i.e.where outside agreed ZTAS ranges) are reported as adverse events to the Leyden Delta Drug Safety department, who may then contact the responsible healthcare professional for further details.Upon review of your patient' s health and blood results, if you consider any other abnormalities to the blood parameters(excluding those mentioned above) or if you signal abnormalities to physical or mental symptoms to be clinically significant, please ensure that you report these as adverse events.Reports of adverse events can be made to the MHRA directly via the Yellow Card scheme at www.mhra.gov.uk/yellowcard or the MHRA Yellow Card app.Adverse events should also be reported to Leyden Delta via info@ztas.co.uk or via telephone number 0207 3655 842.
DECLARATION
This document is my statement of intent to participate in the prescribing and monitoring of Zaponex® (clozapine) in association with the ZTAS.Signing of this form confirms my commitment to adhere to the Zaponex SPC and the ZTAS manual and confirms that I am an appropriate specialist for the supervision of Zaponex therapy.Signing of this form also constitutes a confirmation of my understanding of, and commitment to, my responsibilities in respect of maintaining the confidentiality of my patient's details and reporting adverse events, as detailed above. I understand that my registration will be confirmed by a return letter, enclosing my unique user ID and password to the ZTAS system and that these details should not be shared, in order to prevent unauthorised access to patient data. Should I no longer require access to the ZTAS, or if there are any changes to the patient data under my care, I will inform ZTAS of this within 30 days.I have read the ZTAS privacy notice and understand how my personal data will be used by Leyden Delta.
Prescribing reminders
  • Zaponex may only be prescribed by a consultant or physician who is registered with the ZTAS
  • Zaponex may only be prescribed for patients who are registered with the ZTAS
  • There must always be a current, valid blood result for the patient before any Zaponex is dispensed

Submission Date Signature
13-Jul-2020