Clozaril Registry Form

CSAN® FORM (Check appropriate procedure below) Enrollment (please complete Sections 1-4) Modification (please complete and sign as applicable) Discontinuation (please complete Sections 1 & 5) CSAN® FAX: 1-800-465-1312 CSAN® TEL. CSAN® FORM (Check appropriate procedure below) Enrollment (please complete Sections 1-4) Modification (please complete and sign as applicable) Discontinuation (please complete Sections 1 & 5) CSAN® FAX: 1-800-465-1312 CSAN® TEL. The patient will appear on your patient list with an Active or Pending status. The patient will appear on your patient list with an Active or Pending status. Rosemont, PA 19010 (844) 457-8721. Rosemont, PA 19010 (844) 457-8721. Full name and title if being signed by the lead clozaril® pharmacist: by signing this form, i confirm that the supervising specialist is aware of the registration with. Full name and title if being signed by the lead clozaril® pharmacist: by signing this form, i confirm that the supervising specialist is aware of the registration with. Rosemont, PA 19010 (844) 457-8721. Rosemont, PA 19010 (844) 457-8721. ®CLOZARIL may only be prescribed for and dispensed to patients who are registered with the CLOZARIL® Patient Monitoring Service (CPMS). ®CLOZARIL may only be prescribed for and dispensed to patients who are registered with the CLOZARIL® Patient Monitoring Service (CPMS). Cdr Author: Diya Created Date: 7/22/2021 3:48:42 PM. Cdr Author: Diya Created Date: 7/22/2021 3:48:42 PM. Full name and title if being signed by the lead clozaril® pharmacist: by signing this form, i confirm that the supervising specialist is aware of the registration with. Full name and title if being signed by the lead clozaril® pharmacist: by signing this form, i confirm that the supervising specialist is aware of the registration with. The required Serious Adverse Event form(s) and send this form(s) directly to AA-Clozapine Patient Care Network within 24 hours via fax to 18668366778 or report via phone to 18772762569. The required Serious Adverse Event form(s) and send this form(s) directly to AA-Clozapine Patient Care Network within 24 hours via fax to 18668366778 or report via phone to 18772762569. To obtain a Teva Eligibility Code/ID casodex tablet submit this form to: Teva Clozapine Patient Registry 50 NW 176th Street, Butler Building, Second Floor Miami, Florida 33169 Phone: Fax: Internet: 1-800-507-8334 1-800-507-8339 www. To obtain a Teva Eligibility Code/ID submit this form to: Teva Clozapine Patient Registry 50 NW 176th Street, Butler Building, Second Floor Miami, Florida 33169 Phone: Fax: Internet: 1-800-507-8334 1-800-507-8339 www. O If an ANC is missing, the prescriber is required to provide authorization to continue therapy. O If an ANC is missing, the prescriber is required to provide authorization to continue therapy. The modification to Clozapine REMS will go into effect on November 15, 2021. The modification to Clozapine REMS will go into effect on November 15, 2021. 3 The Clozapine REMS (Risk Evaluation and Mitigation Strategy) is a safety program required by the Food and Drug Administration (FDA) to manage the risk of severe neutropenia associated with clozapine treatment. 3 The Clozapine REMS (Risk Evaluation and Mitigation Strategy) is a safety program required by the Food and Drug Administration (FDA) to manage the risk of severe neutropenia associated with clozapine treatment. Full name and title if being signed by the lead clozaril® pharmacist: by signing this form, i confirm that the supervising specialist is aware of the registration with. Full name and title if being signed by the lead clozaril® pharmacist: by signing this form, i confirm that the supervising specialist is aware of the registration with. Phone: 1-877-276-2569 / Fax: 1-866-836-6778 / W. Phone: 1-877-276-2569 / Fax: 1-866-836-6778 / W. CareLink Plus Contact Details: carelinkplus@viatris. CareLink Plus Contact Details: carelinkplus@viatris. CLOZARIL is available only clozaril registry form from pharmacies registered with the CNR (CLOZARIL National Registry). CLOZARIL is available only from pharmacies registered with the CNR (CLOZARIL National Registry). The system will search the database. The system will search the database. Important changes include: All prescribers and pharmacies must be re-certified by November 15, 2021, or they will no longer be able to prescribe/dispense clozapine. Important changes include: All prescribers and pharmacies must be re-certified by November 15, 2021, or they will no longer be able to prescribe/dispense clozapine. O If an ANC is missing, the prescriber is required to provide authorization to continue therapy. O If an ANC is missing, the prescriber is required to provide authorization to continue therapy. Clozapine Tablets, USP (Accord Healthcare) Clozapine Tablets, USP (Aurobindo Pharma USA) Clozapine Tablets, USP (Aurobindo Pharma USA) Clozapine (Heartwood Pharma). Clozapine Tablets, USP (Accord Healthcare) Clozapine Tablets, USP (Aurobindo Pharma USA) Clozapine Tablets, USP (Aurobindo Pharma USA) Clozapine (Heartwood Pharma). 6 Infection, including skin, throat, urinary tract, vaginal, pneumonia, or any other infection. 6 Infection, including skin, throat, urinary tract, vaginal, pneumonia, or any other infection. Distributed by: HLS Therapeutics (USA), Inc. Distributed by: HLS Therapeutics (USA), Inc. Distributed by: HLS Therapeutics (USA), Inc. Distributed by: HLS Therapeutics (USA), Inc. Creating an account involves creating unique login credentials (username and password). Creating an account involves creating unique login credentials (username and password). Wounds that take a long time to heal. Wounds that take a long time to heal. CPMS Contact Details : cpms@cpharm. CPMS Contact Details : cpms@cpharm. ®CLOZARIL may only be prescribed for patients who are registered with the CLOZARIL® Patient Monitoring Service (CPMS). ®CLOZARIL may only be prescribed for patients who are registered with the CLOZARIL® Patient Monitoring Service (CPMS). Is used to document the monitoringfrequency, ANC values, adverse events related to clozapine-induced neutropenia, and appropriateness to continue treatment. Is used to document the monitoringfrequency, ANC values, adverse events related to clozapine-induced neutropenia, and appropriateness to continue treatment.

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Pain or burning while urinating. Pain or burning while urinating. Both must be registered with cpms to enable processing. Both must be registered with cpms to enable processing. CLIN336 Clozapine Patient Registration Form (Revised 10/29/2012). CLIN336 Clozapine Patient Registration Form (Revised 10/29/2012). Cdr Author: Diya Created Date: 7/22/2021 3:48:42 PM. Cdr Author: Diya Created Date: 7/22/2021 3:48:42 PM. Your health care prescriber will be responsible for maintaining your blood count records. Your health care prescriber will be responsible for maintaining your blood count records. Review each drug's Prescribing Information. Review each drug's Prescribing Information. O A Patient Status Form must be received within 37 calendar days after the date of. O A Patient Status Form must be received within 37 calendar days after the date of. Title: 20210722_MS2188_CPMS_Patient_Registration_Re-Registration_V9_THS. Title: 20210722_MS2188_CPMS_Patient_Registration_Re-Registration_V9_THS. The required Serious Adverse Event form(s) and send this form(s) directly to AA-Clozapine Patient Care Network within 24 hours via fax to 18668366778 or report via phone to 18772762569. The required Serious Adverse Event form(s) and send this form(s) directly to AA-Clozapine Patient Care Network within 24 hours via fax to 18668366778 or report via phone to 18772762569. AA-Clozapine Patient Care Network - PATIENT REGISTRATION. AA-Clozapine Patient Care Network - PATIENT REGISTRATION. O Patient monitoring must still continue per the Prescribing Information. O Patient monitoring must still continue per the Prescribing Information. Infection, including skin, throat, urinary tract, vaginal, pneumonia, or any other infection. Infection, including skin, throat, urinary tract, vaginal, pneumonia, or any other infection. Beginning August 2, 2021, a Transition Contact Center is available at 888-586-0758 to support re-certification, re-enrollment. Beginning August 2, 2021, a Transition Contact Center is available at 888-586-0758 to support re-certification, re-enrollment. Only enough CLOZARIL tablets are given to last until the next dispense date pending status. Only enough CLOZARIL tablets are given to last until the next dispense date pending status. Clozaril ® is marketed by Mylan Products Limited in the UK, and Mylan IRE Healthcare Limited in Ireland. Clozaril ® is marketed by Mylan Products Limited in the UK, and Mylan IRE Healthcare Limited in Ireland. O A Patient Status Form must be received within 37 calendar days after the date of. O A Patient Status Form must be received within 37 calendar days after the date of. : 1-800-BC ONLY, FAX TO: 1-604-689-1262 267-27. : 1-800-BC ONLY, FAX TO: 1-604-689-1262 267-27. Have the authorized representative enroll in the Clozapine REMS by completing the Pharmacy Enrollment Form and submitting it to the Clozapine REMS. Have the authorized representative enroll in the Clozapine REMS by completing the Pharmacy Enrollment Form and clozaril registry form submitting it to the Clozapine REMS. Before prescribing Clozaril, please refer to the Clozaril ® Data Sheet and appropriate local treatment guidelines • Document the ANC on the Patient Status Form and submit this form monthly. Before prescribing Clozaril, please refer to the Clozaril ® Data Sheet and appropriate local treatment guidelines • Document the ANC on the Patient Status Form and submit this form monthly. Severe neutropenia (absolute neutrophil count (ANC) less than 500/µL), can lead to serious and fatal infections United Kingdom Ireland; Tel: 0845 769 8269 Fax: 0845 769 8379 or 8541 Tel: (01) 662 1141 Fax: (01) 662 5961. Severe neutropenia (absolute neutrophil count (ANC) less than 500/µL), can lead to serious and fatal infections United Kingdom Ireland; Tel: 0845 769 8269 Fax: 0845 769 8379 or 8541 Tel: (01) 662 1141 Fax: (01) 662 5961. There must always be a current valid blood result for the patient and the patient status must be ACTIVE before any CLOZARIL® is dispensed. There must always be a current valid blood result for the patient and the patient status must be ACTIVE before any CLOZARIL® is dispensed. O A Patient Status Form must be received within 37 calendar days after the date of. O A Patient Status Form must be received within 37 calendar days after the date of. Mylan UK Healthcare Limited (company registration number 09189103), an English company with a registered office address at 20 Station Close, Potters Bar, Hertfordshire, EN6 1TL (VAT - 421 623 781). Mylan UK Healthcare Limited (company registration number 09189103), an English company with a registered office address at 20 Station Close, Potters Bar, Hertfordshire, EN6 1TL (VAT - 421 623 781). Pain or burning while urinating. Pain or burning while urinating. Is used to document the monitoringfrequency, ANC values, adverse events related to clozapine-induced neutropenia, and appropriateness to continue treatment. Is used to document the monitoringfrequency, ANC clozaril registry form values, adverse events related to clozapine-induced neutropenia, and appropriateness to continue treatment. CLIN336 Clozapine Patient Registration Form (Revised 10/29/2012). CLIN336 Clozapine Patient Registration Form (Revised 10/29/2012). O Patient monitoring must still continue per the Prescribing Information. O Patient monitoring must still continue per the Prescribing Information. To perform REMS functions online, you must have an account. To perform REMS functions online, you must have an account. Full name and title if being signed by the lead clozaril® pharmacist: by signing this form, i confirm that the supervising specialist is aware of the registration with. Full name and title if being signed by the lead clozaril® pharmacist: by signing this form, i confirm that the supervising specialist is aware of the registration with. CLIN336 Clozapine Patient Registration Form (Revised 10/29/2012). CLIN336 Clozapine Patient Registration Form (Revised 10/29/2012). Online or Print Inpatient or Print Outpatient. Online or Print Inpatient or Print Outpatient. If not, call the Teva Clozapine Patient Registry at 1-800-507-8334. If not, call the Teva Clozapine Patient Registry at 1-800-507-8334. Cdr Author: Diya Created Date: clozaril registry form 7/22/2021 3:48:42 PM. Cdr Author: Diya Created Date: 7/22/2021 3:48:42 PM.

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Phone: 1-877-276-2569 / Fax: 1-866-836-6778 / W. Phone: 1-877-276-2569 / Fax: 1-866-836-6778 / W. Is used to document the monitoringfrequency, ANC values, adverse events related to clozapine-induced neutropenia, and appropriateness to continue treatment. Is used to document the monitoringfrequency, ANC values, adverse events related to clozapine-induced neutropenia, and appropriateness to continue treatment. • Document the ANC on the Patient Status Form and submit this form monthly. • Document the ANC on the Patient Status Form and submit this form monthly. CLZ-2020-0138 Date of preparation: July 2021. CLZ-2020-0138 Date of preparation: July 2021. This form must be signed by either the supervising specialist or lead clozaril® pharmacist responsible for this patient. This form must be signed by either the supervising specialist or lead clozaril® pharmacist responsible for this patient. Unusual vaginal discharge or itching cognino. Unusual vaginal discharge or itching cognino. Before prescribing please review the Approved Clozaril ®(clozapine) Product Information and the CPMS Protocol and ensure you have obtained informed consent from your patient form. Before prescribing please review the Approved Clozaril ®(clozapine) Product Information and the CPMS Protocol and ensure you have obtained informed consent from your patient form. Unusual vaginal discharge or itching User Id. Unusual vaginal discharge or itching User Id. CLOZARIL® PRESCRIBING & DISPENSING PROTOCOL 1. CLOZARIL® PRESCRIBING & DISPENSING PROTOCOL 1. Then re-enroll your patients using the Patient Enrollment Form. Then re-enroll your patients using the Patient Enrollment Form. 3 Title: 20210722_MS2188_CPMS_Patient_Registration_Re-Registration_V9_THS. 3 Title: 20210722_MS2188_CPMS_Patient_Registration_Re-Registration_V9_THS. Prescribers must re-enroll their patients who will continue clozapine by November 15, 2021 form. Prescribers must re-enroll their patients who will continue clozapine by November 15, 2021 form. CLZ-2020-0138 Date of preparation: July 2021. CLZ-2020-0138 Date of preparation: July 2021. This form must be signed by either the supervising specialist or lead clozaril® pharmacist responsible for this patient. This form must be signed by either the supervising specialist or lead clozaril® pharmacist responsible for this patient. Clozaril ® is marketed by Mylan Products Limited in the UK, and Mylan IRE Healthcare Limited in Ireland. Clozaril ® is marketed by Mylan Products Limited in the UK, and Mylan IRE Healthcare Limited in Ireland. Sores or ulcers inside your mouth, gums, or on your skin. Sores or ulcers inside your mouth, gums, or on your skin. CLOZARIL is available in 25-mg and 100-mg tablets. CLOZARIL is available in 25-mg and 100-mg tablets. Both must be registered with cpms to enable processing. zyloprim 100mg tablet Both must be registered with cpms to enable processing. Registry staff will then verify the data and confirm the registration. Registry staff will then verify the data and confirm the registration. This form must be signed by either the supervising specialist or lead clozaril® pharmacist responsible for this patient. This form must be signed by either the supervising specialist or lead clozaril® pharmacist responsible for this patient. O Patient monitoring must still continue per the Prescribing Information. O Patient monitoring must still continue per the Prescribing Information. Both must be registered with cpms to enable processing. Both must be registered with cpms to enable processing. Wounds that take a long time to heal. Wounds that take a long time to heal. To clozaril registry form obtain a Teva Eligibility Code/ID submit this form to: Teva Clozapine Patient Registry 50 NW 176th Street, Butler Building, Second Floor Miami, Florida 33169 Phone: Fax: Internet: 1-800-507-8334 1-800-507-8339 www. To obtain a Teva Eligibility Code/ID submit this form to: Teva Clozapine Patient Registry 50 NW 176th Street, Butler Building, Second Floor Miami, Florida 33169 Phone: Fax: Internet: 1-800-507-8334 1-800-507-8339 www. Important changes include: All prescribers and pharmacies must be re-certified by November 15, 2021, or they will no longer be able to prescribe/dispense clozapine. Important changes include: All prescribers and pharmacies must be re-certified by November 15, 2021, or they will no longer be able to prescribe/dispense clozapine.