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This is the text extract for PCT Paediatric Oncology/Haematology Notification Form, browse documents here.


Pharmaceutical Cancer Treatments Paediatric Oncology/Haematology Notification Form

Return completed form to: Panel Coordinator, PHARMAC 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)

Metadata

Title

PCT Paediatric Oncology/Haematology Notification Form

Abstract

Pharmaceutical Cancer Treatments Paediatric Oncology/Haematology Notification Form Return completed form to: Panel Coordinator, PHARMAC 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 nameā€¦

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