This is the text extract for Special Circumstance Application form for Acitretin/Isotretinoin , browse documents here.

Special Circumstance Application form for Acitretin/Isotretinoin Please fax this form to: Ministry of Health, Sector Services – 0800 100 131

Note: The Special Circumstance approval number will only cover repeat dispensings of acitretin or isotretinoin where the original was dispensed prior to 1 March 2009. Any original dispensing made on or after 1 March 2009 will require a Special Authority approval number.

PHARMACY INFORMATION

Claimant Number Claimant Name Contact Person Phone Number Fax Number

PRESCRIBER INFORMATION

MCNZ Name Address

PATIENT INFORMATION

NHI Number Surname First Name Address Date of Birth

PHARMACEUTICAL INFORMATION

Prescription Number Period of supply Acitretin Isotretinoin First Dispensed

Pharmaceutical (please tick)

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