Via this Form the registration of multiple patients in a switch project with the Zaponex Treatment Access System (ZTAS®) is confirmed. We will use the information you provided about your patients in accordance with the terms explained in the ZTAS privacy notice which is available from the ZTAS website www.ztas.co.uk.
All patients who are treated with Zaponex® (clozapine) must be registered with ZTAS. Additionally, all patients prescribed Zaponex®, or another clozapine brand, experiencing a leukopenia and/or neutropenia will be enrolled on a separate database, the Central Non Re-challenge Database (CNRD). The CNRD maintains a central record of these adverse reactions to prevent harmful re-exposure to clozapine. The CNRD is controlled by an independent company, CNRD 2002 Ltd.
Dear (Clozapine) Pharmacist,
Re: Confirmation and Authorisation of ZTAS Patient Registrations (Bulk Switch)
Please complete this form to authorise the registration of the patients to ZTAS on behalf of your Trust. Your signature will confirm the registration for all patients included in the patient list attached to the email through which you accessed this form.
We kindly ask that you review the patient list for accuracy and confirm that all information is complete and correct before submitting this form.
DECLARATION
The information you provide about your patients will be held on the ZTAS database and constitutes their personal and special category personal data. This data will be processed in accordance with applicable data protection legislation in order to monitor your patients' blood results and to assist you and/or other healthcare professionals to make medical decisions regarding your patients’ health and to provide you and/or your patients with services connected with ZTAS.
Your patients’ data and blood samples may be used now or in the future in connection with further research by Leyden Delta (or sponsors whether or not associated with Leyden Delta). Such purposes may or may not be related to Zaponex and/or services connected to it and may also be published (your patients will not be identified in any publications resulting from such research).
The information on your patients held on the CNRD will be held for the sole purpose of preventing re-exposure to clozapine and will only be made available to the suppliers of clozapine.
Yours sincerely,
Zaponex Treatment Access System
I certify that, to the best of my knowledge, the patient information provided is true and accurate. I confirm that I have explained to my patients/their guardians that their information and blood samples relating to them will be processed as described above and in accordance with the terms of the ZTAS privacy notice and I have obtained their consent to undergo treatment.
