Change To Patient Details Form

This form is used to inform ZTAS of changes to details of patients registered with the ZTAS. For the safety of patients treated with Zaponex® (clozapine) and to ensure an adequate and efficient monitoring service, it is necessary that the ZTAS database be properly maintained.

We will use the information provided on this form in accordance with the terms of the ZTAS privacy notice which is available from the ZTAS website www.ztas.co.uk.

Patient Identifiers
ZTAS PIN		Date Of Birth	- -
Name
NHS number
	* If this is a name change or correction, or if this is a DOB correction, please include details in the Comments section

Changes to monitoring situation (tick all that apply and complete details of the changes)
Patient has discontinued	Date of discontinuation	- -
	Please keep in mind that follow-up blood monitoring is required as part of the discontinuation procedure.
Patient has a Treatment Break	From	- -
	Until/restart	- -
	Restart date MUST be provided in order to register a Treatment Break in ZTAS.

New or changed Consultant and/or Location details (tick all that apply and complete details of the changes)
Consultant			GMC
Treatment Location
Contact person			Postcode
Dispensing Pharmacy			Postcode
Blood Sampling Location
Contact person			Postcode

Comments / other changes

Completed by	(cannot be actioned unless signed)
Name		ZTAS User ID
Phone number
Personal email
	Example: john.smith@nhs.net. Please do not use group email addresses or gmail/yahoo, etc.
Submission Date	25-Apr-2024	Signature Undo Clear