Read ThalidomideIEOrderForm.pdf text version

Thalidomide CelgeneTM Order Form

Orders will not be processed unless a fully completed and signed order form is faxed to United Drug Distribution (UDD), for the attention of UDD Quality Department (Fax: 01 4632404).

Pharmacy Details Ordered by: (Please print full name and position e.g. Irish registered pharmacist/technician)

Pharmacy Name & address: (Please print)

Pharmacy Stamp

Pharmacy Telephone:

Please indicate your nominated Wholesaler: (Please tick)

Dublin Ballina Limerick Galway Drug UD CMR Dublin Cork Sligo Uniphar Dublin Cork Limerick Sligo

Patient Details Prescribing physician (Please) Treating Hospital Indication Male Woman of childbearing potential (WCBP) Woman of non-childbearing potential (WNCBP) Dose of Thalidomide Celgene being prescribed Product Description Thalidomide Celgene Capsules Comments Strength 50mg Date of prescription Quantity required Patient Date of Birth

tick tick tick

I confirm that I am ordering on behalf of a registered pharmacy and that Thalidomide Celgene will be dispensed in accordance with the risk minimisation procedures for Thalidomide Celgene, as specified by Celgene in the Thalidomide Celgene Healthcare Professional's Information Pack. I confirm that dispensing will be within 7 days of the date of prescription and that no more than one month's supply will be dispensed at any one time.

Sign

Date

© Celgene Limited 2011 THAL/215/05-11/05-13

Telephone Print

FOR INTERNAL USE ONLY:

Supply Approval: ________________________________________ Order Processed by: ______________________________________ Batch Number: ________________________________________ Invoice/Order Ref: ______________________________________ Date: ____________________________________________ Date: ____________________________________________ Expiry Date: ______________________________________

QPF

Issue

Effective Date

Information

HCP

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