This is the text extract for SA0657 – Clarithromycin, browse documents here.

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

APPLICATION FOR WAIVER OF RULE BY SPECIAL AUTHORITY

Page 1

Form SA0657

September 2009

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

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

Clarithromycin

INITIAL APPLICATION - Helicobacter pylori infections Applications only from a general practitioner or relevant specialist. Approvals valid for 6 months. Prerequisites (tick boxes where appropriate)

and

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Eradication of Helicobacter pylori in patient with proven infection Peptic ulcer disease proven by endoscopy

Note: Maximum of two prescriptions (two courses) per patient.

INITIAL APPLICATION - Mycobacterial infections Applications only from a respiratory specialist, infectious disease specialist or paediatrician. Approvals valid for 2 years. Prerequisites (tick boxes, and write the data requested in the space provided where appropriate)

or or

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and and

Mycobacterium Avium Intracellulare Complex infections in patient with AIDS Atypical and drug-resistant mycobacterial infection

Prophylaxis against disseminated Mycobacterium Avium Intracellulare Complex infection HIV infection

CD4 count: ......................................≤ 50 cells/mm³

RENEWAL - Mycobacterial infections Current approval Number (if known):............................................................... Applications only from a respiratory specialist, infectious disease specialist or paediatrician. Approvals valid for 2 years. Prerequisites (tick box where appropriate)

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The treatment remains appropriate and the patient is benefiting from treatment

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