Private and Confidential (When Complete) Cimzia® (certolizumab pegol) Homecare Service - Patient Registration Form Homecare Provider: Healthcare at Home. Therapy Area / Service: PA Pharmaceutical Funder / Manufacturer: UCB Pharmaceuticals Ltd. Hospital Name [Hemel Hampstead General Hospital Hospital Address _|Hillfield Road, Hemel Hampstead, HP2 4AD_ PATIENT DETAILS NHS number: [478 251 6589 Hospital number: [aas7aa2 [Mandatory Diagnosis: __ |AxHomecare Tech, Forename|Rosie [Consultant Name: Ic.Green \Title |Miss Surname: [Cheeks (Consultant Phone: lext 2347 Date of birth: 31.01.98 Nurse Specialist Name: _[R. Bown ‘address: [7 Walnut Grove [Nurse Specialist Phone: [ext 5892 |Hemel Hempstead (Address label con be Clinical Pharmacist Name: _[C.Balding |orised here) cinical Pharmacist Phone: lex 5487 Postcode: HP2 aap [GP Name: Gender: Male) Female 6 GP Surgery Preferred phone: lo1ase 457412 Parent/Carer name: ‘Alternative phone Relationship to patient ok toleaveamessage? |vesC) NoO Parent/carer phone: [Email address: rosiecheeks4@icloud.com | SERVICE REQUIREMENTS [New patient 63 Switch provider) __Switch therapy) Service Required Delivery & Nurse Training O Delivery only Date 1* delivery required Delivery Address @#e=rttosb0r! [Chiltern Timber Supplies LTD, Blossom Way, Hemel Hempstead, HP2 428 Is Cimzia to be supplied with Methotrexate? Yes C) No Gd _ tyes, please supply a combined presexption) REFERRING PHYSICIAN/HEALTHCARE PROFESSIONAL Ihave discussed the Homecare service with the above-named patient and provided sufficient information to allow the patient to agree to the homecare servce, the related processing of their personal data and the patient has agreed to referral into the homecare service > The patient has given permission to be contacted by the homecare service provider in order to provide ther withthe required Information to complete their registration to receive the services. > \confirm that an appropriate home suitability assessment has been completed and the patients suitable for the homecare service. > | have considered all contraindications and screening requirements when prescriing this therapy, 1 contiem | have informed the patient that this homecare service is funded by a pharmaceutical company. >t confirm that funding sin place as per the details below Signature: IName:(oleose erat [C.Green [Date: |oz.01.21 INVOICING DETAILS & ADMINSTRATIVE CONTACTS [Homecare Tech, Pharmacy invoice Contact name: [West Hertfordshire NHS Trust Invoice address: (if Sores [Contact phone number: [01923 831540 [AAU Level 2, Vicarage Road different from hospital {Herts |wo18 HB Invoice account name: Homecare lead name Homecare lead phone: Contact Name for RX satterson [Contact Telfor Rx Lo. as a¢5g6g Renewals: Renewals: | [Contact email for Rx Renewals: EJefferson@nhs.net, ‘This Patient Registration Form must be forwarded with a valid prescription to the Hospital's Pharmacy Department (Homecare Team) prior to transmission to the selected Homecare Provider. ocumont it: Contokzumab pepo CIMZA; Rast avon Form Bocumons Raferen Verso nume- 10 impiomenttionO ecifens/2162 19/05/2019,