Treatment location

A   

Please complete this form using black ink.
Name facility
Address

Town/City
Contact number
:
:
:
Ward :

Postcode :
This form is used to register and de-register a patient with the Zaponex Treatment Access System (ZTAS®). for patients : Fax :
Patients who are treated with Zaponex® must be registered on Genthon’s ZTAS database. Additionally, all patients prescribed Zaponex
(or any other clozapine drug) experiencing a leucopenia and/or neutropenia, will be enrolled on a separate database, the Central Non Pharmacy address
Re-challenge Database (CNRD).The CNRD maintains a central record of such adverse reactions to prevent harmful re-exposure to
clozapine.The CNRD is controlled by an independent company, CNRD 2002 Ltd. Pharmacy name :

Address :
Registration De-registration
Town/City :
Patient details
Laboratory used for ZTAS blood analysis Central* Local
NHS Number : - -
Local laboratory: NEQAS certified : Yes No
Surname
Name :
Address :
Initials First name

(Any known aliases for this patient should be completed in the Comments section for this patient) Town/City : Postcode :
d d m m y y y y
Date of birth : Sex : Male Female Telephone : Fax :
* Please also complete the address of the local laboratory when the central laboratory is used (for urgent samples).
Race : Caucasian Afro-Caribbean Asian Mixed* Other*

* please specify : Shipment address for blood kits

Blood group : O- O+ A- A+ B- B+ AB- AB+ Not available
Facility name :
Patient treatment status : New On-Treatment Interrupted Stop treatment #

Contact person :
#
specify reason : Transferred Discontinued Non Re-challengeable Deceased
Address :

Town/City : Postcode :
On-treatment patients
Telephone :
Current monitoring frequency : Weekly Fortnightly 4-weekly
d d m m y y y y The information on your patient held on the ZTAS will be processed in accordance with the Data Protection Act 1998 in order to monitor your patient’s
Most recent start date clozapine therapy : blood results and to assist you and/or other healthcare professionals to make medical decisions regarding such patient’s health and to provide you and/or
your patient with services connected with Zaponex.Your patient’s personal data may be used, now or in the future, in connection with further research by
Patient is eligible for Zaponex treatment : Yes No Genthon (or companies associated with Genthon) in relation to Zaponex and services connected with Zaponex and may also be published (although your
patient will not be identified in any publications resulting from such research).The information on your patient held on the CNRD will be held for the
Shared care : Yes No sole purpose of preventing re-exposure to clozapine and will only be made available to the suppliers of clozapine.

Under the Data Protection Act 1998, Genthon is required to obtain and process personal data fairly and lawfully. Since it would not be appropriate
Most recent blood results 1 2 3 (most recent) for Genthon to contact your patient to obtain their consent to such processing of personal data as outlined above, we request that you provide the
information regarding the processing of your patient’s personal data.
d d m m y y y y d d m m y y y y d d m m y y y y
Date of analysis :
Completed by Consultant Psychiatrist:
White Blood Cell Count (x 10 /L) :
9
. . . I, the psychiatrist, certify that to the best of my knowledge the completed information is true and accurate and that I have explained to
my patient the reason as described above for processing this information.
Neutrophil Count (x 10 /L) 9
: . . .
Name :   
Platelet Count (x 10 /L)
9
: . . .
Consultant Psyc hiatr ist
d d m m y y y y
New/interrupted patients (to be completed by ZTAS): Date : Signature :

d d m m y y y y
Patient in CNRD : Yes No Date :
Completed by Pharmacist:
I, the pharmacist, have taken notice that this patient will be registered with the ZTAS and treated with Zaponex.
ZTAS Employee

Name : Signature :   
Name :
Form.01.SOP.NL02.305.01

Form.01.SOP.NL02.305.01
Comments : Phar macist
d d m m y y y y
Date : Signature :

Please fax this form to ZTAS on 0207 3655843

Page 1 of 2 Surname patient: Page 2 of 2
 Treatment location

A   

Please complete this form using black ink.
Name facility
Address

Town/City
Contact number
:
:
:
Ward :

Postcode :
This form is used to register and de-register a patient with the Zaponex Treatment Access System (ZTAS®). for patients : Fax :
Patients who are treated with Zaponex® must be registered on Genthon’s ZTAS database. Additionally, all patients prescribed Zaponex
(or any other clozapine drug) experiencing a leucopenia and/or neutropenia, will be enrolled on a separate database, the Central Non Pharmacy address
Re-challenge Database (CNRD).The CNRD maintains a central record of such adverse reactions to prevent harmful re-exposure to
clozapine.The CNRD is controlled by an independent company, CNRD 2002 Ltd. Pharmacy name :

Address :
Registration De-registration
Town/City :
Patient details
Laboratory used for ZTAS blood analysis Central* Local
NHS Number : - -
Local laboratory: NEQAS certified : Yes No
Surname
Name :
Address :
Initials First name

(Any known aliases for this patient should be completed in the Comments section for this patient) Town/City : Postcode :
d d m m y y y y
Date of birth : Sex : Male Female Telephone : Fax :
* Please also complete the address of the local laboratory when the central laboratory is used (for urgent samples).
Race : Caucasian Afro-Caribbean Asian Mixed* Other*

* please specify : Shipment address for blood kits

Blood group : O- O+ A- A+ B- B+ AB- AB+ Not available
Facility name :
Patient treatment status : New On-Treatment Interrupted Stop treatment #

Contact person :
#
specify reason : Transferred Discontinued Non Re-challengeable Deceased
Address :

Town/City : Postcode :
On-treatment patients
Telephone :
Current monitoring frequency : Weekly Fortnightly 4-weekly
d d m m y y y y The information on your patient held on the ZTAS will be processed in accordance with the Data Protection Act 1998 in order to monitor your patient’s
Most recent start date clozapine therapy : blood results and to assist you and/or other healthcare professionals to make medical decisions regarding such patient’s health and to provide you and/or
your patient with services connected with Zaponex.Your patient’s personal data may be used, now or in the future, in connection with further research by
Patient is eligible for Zaponex treatment : Yes No Genthon (or companies associated with Genthon) in relation to Zaponex and services connected with Zaponex and may also be published (although your
patient will not be identified in any publications resulting from such research).The information on your patient held on the CNRD will be held for the
Shared care : Yes No sole purpose of preventing re-exposure to clozapine and will only be made available to the suppliers of clozapine.

Under the Data Protection Act 1998, Genthon is required to obtain and process personal data fairly and lawfully. Since it would not be appropriate
Most recent blood results 1 2 3 (most recent) for Genthon to contact your patient to obtain their consent to such processing of personal data as outlined above, we request that you provide the
information regarding the processing of your patient’s personal data.
d d m m y y y y d d m m y y y y d d m m y y y y
Date of analysis :
Completed by Consultant Psychiatrist:
White Blood Cell Count (x 10 /L) :
9
. . . I, the psychiatrist, certify that to the best of my knowledge the completed information is true and accurate and that I have explained to
my patient the reason as described above for processing this information.
Neutrophil Count (x 10 /L) 9
: . . .
Name :   
Platelet Count (x 10 /L)
9
: . . .
Consultant Psyc hiatr ist
d d m m y y y y
New/interrupted patients (to be completed by ZTAS): Date : Signature :

d d m m y y y y
Patient in CNRD : Yes No Date :
Completed by Pharmacist:
I, the pharmacist, have taken notice that this patient will be registered with the ZTAS and treated with Zaponex.
ZTAS Employee

Name : Signature :   
Name :
Form.01.SOP.NL02.305.01

Form.01.SOP.NL02.305.01
Comments : Phar macist
d d m m y y y y
Date : Signature :

Please fax this form to ZTAS on 0207 3655843

Page 1 of 2 Surname patient:. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Page 2 of 2