This is the text extract for Pharmaceutical Cancer Treatments Paediatric Oncology/Haematology Notification Form, browse documents here.
Pharmaceutical Cancer Treatments Paediatric Oncology/Haematology Notification Form
Return completed form to: Exceptional Circumstances Panel Coordinator Phone: Fax: 04 916 7553 09 523 6870
Patient details Last name First name Date of birth NHI number Prescribing practitioner details Last name First name NZMC number Dispensing pharmacy DHB Hospital Fax number Indication
Treatment Chemical name Formulation Brand Pharmacode Start date Contact name Phone number
A197090
Fax completed form to (09) 523 6870 (diverts to Wellington)
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Title
Pharmaceutical Cancer Treatments Paediatric Oncology/Haematology Notification Form
Abstract
Pharmaceutical Cancer Treatments Paediatric Oncology/Haematology Notification Form Return completed form to: Exceptional Circumstances Panel Coordinator Phone: Fax: 04 916 7553 09 523 6870 Patient details Last name First name Date of birth NHI number Prescribing practitioner details Last name First…
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