This is the text extract for SA0947 Isotretinoin, browse documents here.

Ministry of Health Phone 0800 243 666 APPLICANT (stamp or sticker acceptable)

APPLICATION FOR SUBSIDY BY SPECIAL AUTHORITY

Page 1

Form SA0947

PATIENT NHI: ...................................................... REFERRER Reg No: ............................................

Reg No: ................................................................ First Names: ......................................................... First Names: ......................................................... Name: ................................................................... Surname: .............................................................. Surname: .............................................................. Address: ............................................................... DOB: ..................................................................... Address: ............................................................... ............................................................................... Address: ............................................................... ............................................................................... ............................................................................... ............................................................................... ............................................................................... Fax Number: ......................................................... ............................................................................... Fax Number: .........................................................

Isotretinoin

INITIAL APPLICATION Applications from any relevant practitioner. Approvals valid for 1 year. Prerequisites (tick boxes where appropriate)

and and and

u u u u

Patient has had an adequate trial on other available treatments and has failed these treatments or these are contraindicated Applicant is a vocationally registered dermatologist, vocationally registered general practitioner, or nurse practitioner working in a relevant scope of practice Applicant has an up to date knowledge of the treatment options for acne and is aware of the safety issues around isotretinoin and is competent to prescribe isotretinoin Patient has been counselled and understands the risk of teratogenicity if isotretinoin is used during pregnancy and the applicant has ensured that, for female patients, the possibility of pregnancy has been excluded prior to the commencement of the treatment and that (where applicable) the patient is informed that she must not become pregnant during treatment and for a period of one month after the completion of the treatment

Note: Applicants need to have an up to date knowledge of the treatment options for acne and the safety issues around isotretinoin and be competent to prescribe it. Applicants are recommended to either have used or be familiar with using a decision support tool accredited by their professional body.

RENEWAL Current approval Number (if known):............................................................... Applications from any relevant practitioner. Approvals valid for 1 year. Prerequisites (tick boxes where appropriate)

and and and

u u u u

Patient has had an adequate trial on other available treatments and has failed these treatments or these are contraindicated Applicant is a vocationally registered dermatologist, vocationally registered general practitioner, or nurse practitioner working in a relevant scope of practice Applicant has an up to date knowledge of the treatment options for acne and is aware of the safety issues around isotretinoin and is competent to prescribe isotretinoin Patient has been counselled and understands the risk of teratogenicity if isotretinoin is used during pregnancy and the applicant has ensured that, for female patients, the possibility of pregnancy has been excluded prior to the commencement of the treatment and that (where applicable) the patient is informed that she must not become pregnant during treatment and for a period of one month after the completion of the treatment

Note: Applicants need to have an up to date knowledge of the treatment options for acne and the safety issues around isotretinoin and be competent to prescribe it. Applicants are recommended to either have used or be familiar with using a decision support tool accredited by their professional body.

I confirm the above details are correct and that in signing this form I understand I may be audited. Signed: .............................................................................. Date: ...............................................

Post application to Ministry of Health, Private Bag 3015, Wanganui – Fax: 0800 100 131