Tacrolimus (Prograf®)
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.
CAUTION: Careful monitoring of patients is mandatory.
Criteria
Management of rejection in patients following organ or tissue transplantation, under supervision and direction of a transplant unit. Management includes initiation, stabilisation and review of therapy as required.
Specialist Prescriber
| Signature: | ____________________________________ |
| Name: | ____________________________________ |
| Date: | ____________________________________ |
*To be completed by the specialist initiating drug treatment, and retained by the hospital Pharmacy Department.
March 2009
This web page is managed and authorised by Pharmaceutical Services of Centre for Health Protection of the NSW Department of Health. Last updated: 5 March, 2009