Ibandronate Sodium(Bondronat®)
Highly Specialised Drugs Program Declaration Form*
| Patient's Name: | ____________________________________ | |
| Medical Record Number: | ____________________________________ | |
| Medicare Number: | ____________________________________ |
I certify that the above patient meets the Pharmaceutical Benefits Advisory Committee's criteria for funding under Section 100 of the National Health Act, 1953.
Criteria
Bone metastases from breast cancer
Specialist Prescriber
| Signature: | ____________________________________ |
| Name: | ____________________________________ |
| Date: | ____________________________________ |
*To be completed by the specialist initiating drug treatment, and retained by the hospital Pharmacy Department.
March 2008