This form is used to register a patient 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.
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.