Pharmacist Data Form

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PHARMACIST DATA FORM
This form is used to register as a pharmacist with the Zaponex Treatment Access System (ZTAS®). Pharmacists working at more than one location should submit a Pharmacist Data Form for each location. 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.
 
Clozapine pharmacist
A pharmacist who is the primary contact for ZTAS in the pharmacy at the below address. A clozapine pharmacist can register other pharmacy staff ('proxies') at this pharmacy address and is responsible for updating ZTAS with any changes to any of these details.
 
Pharmacist
A pharmacist who is involved in the treatment of patients with Zaponex® (clozapine) and registered with ZTAS who is not the clozapine pharmacist at this pharmacy address.
 
Pharmacist Details
Profesional Registration
Number
GPCPNI GPC = General Pharmaceutical Council
PNI = Pharmaceutical Society Northern Ireland
 
Title ProfMrMrsMs
Name
Type of contact Clozapine pharmacistPharmacist Job title
Emergency telephone number Office number
Personal email
Pharmacy name
Address
Town/city
Postcode
Notification standard
ZTAS reminders, warnings and alerts will be sent to the registered email address of the Clozapine pharmacist.
* Registration of a group email address requires a Data Sharing Form to be completed and returned
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. 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. 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
  • Zaponex may only be dispensed under the responsibility of a ZTAS registered clozapine pharmacist

Submission Date Signature
13-Jul-2020