Change To Patient Details Form

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Once the form has been completed, it can be submitted by selecting


 
 
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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 13-Jul-2020 Signature