Fax - AA-Clozapine Portal
TRAVEL WAIVERRECIPIENT INFORMATIONSENDER INFORMATIONDate: DATE \@ "d-MMM-yy" 26-Apr-17# of pages incl. cover: FORMTEXT ?????Company: FORMTEXT ?????AA-CLOZAPINE Patient Care NetworkTel: 1-877- 276-2569Fax: 1-866-836-6778 To: MD / CoordinatorFrom: FORMTEXT ?????Tel: FORMTEXT ?????Email: aaspire@aapharma.caFax: FORMTEXT ?????Website:aaspire.caPatient Initials: FORMTEXT ?????Date of Birth: FORMTEXT ????? / FORMTEXT ????? / FORMTEXT ?????DDMMMYYYYPatient AA-Pharma PIN: FORMTEXT ?????Healthcare Number: FORMTEXT ????? / FORMTEXT ?????ProvNumberGender:M FORMCHECKBOX F FORMCHECKBOX Other: FORMTEXT ?????Monitoring Frequency:Weekly FORMCHECKBOX Biweekly FORMCHECKBOX Every Four Weeks FORMCHECKBOX Statement by Treating PhysicianI, the treating physician, request to have the above patient’s pharmacy release FORMTEXT ????? week(s) of his/her AA-Clozapine dose for this patient to self-administer while s/he is travelling away from his/her home.I have provided this patient with a blood work requisition so that s/he may continue his/her WEEKLY monitoring while s/he is away. The requisition provided to the patient does request that a copy of the patient’s hematological results be faxed to the AA-Clozapine Patient Care Network at the fax number 1-866-836-6778.I have obtained a contact phone number for this patient in case of any adverse event relating to his/her blood results and/or his/her AA-Clozapine medication. The patient is aware that s/he will need to be available to be contacted in case of any adverse event. The patient is also aware that if s/he is asked to discontinue his/her medication due to an adverse event or reaction to his/her AA-Clozapine s/he will seek medical advice locally or contact me immediately, stop taking the medication immediately and repeat his/her blood work if necessary.Physician Name:PLEASE PRINTPhysician’s Signature:Date: FORMTEXT ?????/ FORMTEXT ????? / FORMTEXT ?????DDMMMYYYY ................
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