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FazaClo Patient Registry Healthcare Practitioner Enrollment Form Instruction This form is used to enroll a health care practitioner in the FazaClo Patient Registry. I agree to prescribe FazaClo only after verifying patient rechallenge status and an acceptable baseline WBC count 3500/mm3 and ANC 2000/mm3 test results and only after receiving a Patient Registration Number PRN from the FazaClo Patient Registry. All forms must be signed a.

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Complete the Prescriber Enrollment Form Enroll in the REMS by completing the Prescriber Enrollment Form and submitting it to the REMS.

1-800-878-5927.

Pharmacists will need to go to .clozapineREMS.com or call the Call Center at 1-888-586-0758 to verify information and obtain a REMS dispense authorization to dispense . The Pre-Dispense Authorization (PDA) will be replaced by a REMS Dispense Authorization (RDA).

FAZACLO is indicated for reducing the risk of recurrent suicidal behavior in patients with schizophrenia or schizoaffective disorder who are judged to be at chronic risk for re experiencing suicidal behavior, based on history and recent clinical state.

should normally be started at a dose of 12.5 mg once a day. On days 2 and 3 the dose can be increased to 25 mg daily. If the patient is tolerating , the dose can be increased by 25-50 mg a day, until a dose of 300 mg a day is reached. This can usually be achieved in 2-3 weeks.

Both you and your healthcare provider must sign the Patient Enrollment Form for you to receive SPRAVATO® in an outpatient medical office or clinic, excluding emergency departments. Your healthcare provider will provide a copy of the signed form to the SPRAVATO® REMS.

“Prescribing for patients receiving inpatient care does not require prescriber certification in the REMS if the patient is already enrolled in the program.

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Form Packages
Adoption
Bankruptcy
Contractors
Divorce
Home Sales
Employment
Identity Theft
Incorporation
Landlord Tenant
Living Trust
Name Change
Personal Planning
Small Business
Wills & Estates
Packages A-Z
Form Categories
Affidavits
Bankruptcy
Bill of Sale
Corporate - LLC
Divorce
Employment
Identity Theft
Internet Technology
Landlord Tenant
Living Wills
Name Change
Power of Attorney
Real Estate
Small Estates
Wills
All Forms
Forms A-Z
Form Library
Customer Service
Terms of Service
DMCA Policy
About Us
Blog
Affiliates
Contact Us
Privacy Notice
Delete My Account
Site Map
All Forms
Search all Forms
Industries
Forms in Spanish
Localized Forms
Legal Guides
Real Estate Handbook
All Guides
Prepared for You
Notarize
Incorporation services
Our Customers
For Consumers
For Small Business
For Attorneys
Our Sites
US Legal Forms
USLegal
FormsPass
pdfFiller
signNow
airSlate workflows
DocHub
Instapage
Social Media
Call us now toll free:
1-877-389-0141
As seen in:
  • USA Today logo picture
  • CBC News logo picture
  • LA Times logo picture
  • The Washington Post logo picture
  • AP logo picture
  • Forbes logo picture
© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232