Get Prescription Authorisation Form - Celgene

Completing the Prescription Authorisation Form for ® is an essential step for healthcare professionals prescribing this medication. This guide provides a clear, step-by-step process to ensure accurate and efficient completion of the form online.

Follow the steps to accurately complete the form:

1. Press the ‘Get Form’ button to access the Prescription Authorisation Form and open it for editing.
2. In the first section, enter the name of the treating hospital where the patient is receiving care.
3. Fill in the patient's date of birth using the format D D M M Y Y Y Y.
4. Print your name as the prescribing physician clearly in the designated field.
5. Indicate the diagnosis by marking the appropriate box for the patient—options include MDS del (5q) and Multiple Myeloma. If applicable, provide additional details in the 'Other' section.
6. For patients experiencing relapses, select the appropriate box indicating the stage of relapse (1st, 2nd, 3rd+, etc.).
7. Complete the capsule strength prescribed by ticking the correct option (2.5mg, 5mg, 10mg, 15mg, or 25mg) and specify the quantity of capsules per cycle.
8. Indicate the number of cycles prescribed by selecting the appropriate number, and note the total number of capsules in the specified field.
9. Sign and date the form, ensuring that both the prescriber’s and pharmacist’s signatures are included prior to the dispensing of ®.
10. If the patient is of childbearing potential, ensure that counseling regarding the teratogenic risk has been provided, and document the date of the last negative pregnancy test.
11. Confirm the home delivery information, including the name and postcode of the delivery service if applicable.
12. Fax the completed form to Celgene on 0808 100 9910, ensuring that all sections are fully completed to avoid any issues.

Complete your documents online seamlessly today.