This is the text extract for SA0837 – Leuprorelin, browse documents here.

---

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

APPLICATION FOR SUBSIDY BY SPECIAL AUTHORITY

Page 1

Form SA0837

July 2009

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

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

Leuprorelin

INITIAL APPLICATION - Breast cancer Applications from any medical practitioner. Approvals valid for 1 year. Prerequisites (tick box where appropriate)

u

The patient is a premenopausal woman with breast cancer

INITIAL APPLICATION - Prostate cancer Applications only from an oncologist, urologist or endocrinologist. Approvals valid for 1 year. Prerequisites (tick box where appropriate)

u

The patient has advanced prostatic cancer

Note: Not to be prescribed with an anti-androgen except for a period of three weeks, if necessary, when GnRH analogue therapy is intiated

INITIAL APPLICATION - Endometriosis Applications only from a gynaecologist. Approvals valid for 3 months. Prerequisites (tick boxes where appropriate)

and

u u u

or

Endometriosis

6 months treatment with medroxyprogesterone acetate, danazol or dimetriose has proven ineffective The patient has failed to tolerate the treatment with medroxyprogesterone acetate, danazol or dimetriose for 6 months

Note: The maximum treatment period for a GnRH analogue is: • 3 months to assess whether surgery is appropriate • 3 months for infertile patients after surgery • 6 months for patients with symptoms of endometriosis After the first 3 months patients should be assessed to determine whether there has been a satisfactory response to the first 3 months treatment

INITIAL APPLICATION - Precocious puberty Applications only from a paediatrician or endocrinologist. Approvals valid for 1 year. Prerequisites (tick box where appropriate)

u

The patients is affected by gonadotropin dependent precocious puberty

Use next page for: Renewal - Breast or prostate cancer, Renewal - Endometriosis and Renewal - Precocious puberty 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

---

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

APPLICATION FOR SUBSIDY BY SPECIAL AUTHORITY

Page 2

Form SA0837

July 2009

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

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

Leuprorelin - continued

RENEWAL - Breast or prostate cancer Current approval Number (if known):............................................................... Applications from any medical practitioner. Approvals valid for 1 year. Prerequisites (tick box where appropriate)

u

The treatment remains appropriate and the patient is benefiting from treatment

Note: If a patient had an approval for any GnRH analogue prior to 1 July 2006 the applicant is required to submit a fresh initial application, not a renewal application.

RENEWAL - Endometriosis Current approval Number (if known):............................................................... Applications from any medical practitioner. Approvals valid for 3 months. Prerequisites (tick boxes where appropriate)

or

u u u

and

There has been a satisfactory response to the first 3 months treatment Surgery is inappropriate

The first three months of therapy did not follow surgery for infertility

Note: If a patient had an approval for any GnRH analogue prior to 1 July 2006 the applicant is required to submit a fresh initial application, not a renewal application.

RENEWAL - Precocious puberty Current approval Number (if known):............................................................... Applications only from a paediatrician or endocrinologist. Approvals valid for 1 year. Prerequisites (tick box where appropriate)

u

The treatment remains appropriate and the patient is benefiting from treatment

Note: If a patient had an approval for any GnRH analogue prior to 1 July 2006 the applicant is required to submit a fresh initial application, not a renewal application.

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