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Patient Name: _________________________________________________________
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Prescriber Name: _________________________________________________
Phone: _________________________________ Fax: _______________________________
City, State, Zip: ___________________________________________________
Contact Person: __________________________
ICD-9 Code: � ______________________ Diagnosis: _____________________________________________________ Serum Creatinine: ____________________________CD4 Count: __________________________ Viral Load: _____________________________________________________ Lab date: ___________________________________
� Sustiva 600mg tab (take at bedtime)� Isentress 400mg tab
� Trizivir 300/150/300mg tab� Prezista ________ mg tab
� Take ______ tablets ____________ times per day
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By signing below, I authorize Greater Placer Pharmacy to help me enroll in any or all patient co-pay assistance programs, including all foundations and manufacturer assistanceprograms. I authorize any communications among my providers, the pharmacy and the manufacturers regarding my health conditions and medications prescriptions in order tohelp coordinate the delivery of products and services through the various co-pay assistance programs. I understand that I may refuse to sign this form without affecting myability to obtain treatment from the pharmacy. However, my refusal will not allow me to be enrolled in any co-pay assistance programs. If agreed, this signed authorization form(or a copy of this form) will be utilized as the original signed application for any and all possible foundations that may participate in the co-pay assistance programs, and it mayserve such purpose.
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JAMES A. SIMON, M.D. Infertility Menopause/Osteoporosis Gynecology Reproductive Endocrinology Clinical Professor Bisphosphonates and ONJ: Risks, Benefits, and Prevention Carol J. Mack, MPH, PA-C Patricia M. DeHof, CRNP, MS A few years ago, several major news publications published articles regarding the risk of osteonecrosis of the jaw (ONJ) for patients taking drugs called
12.30 — 14.00 / Sunday 26 September / Manchester Town Hall / Banqueting Room e Demos Grill: An in-conversation Oona King; Krishnan Guru-Murthy, Channel 4 News18.00 — 19.30 / Sunday 26 September / Radisson Hotel / Beecham Room Where next for an active British industrial policy? Bob Ainsworth MP; John Woodcock MP; Dan Roberts, The Guardian; Bob Keen, BAE Systems; Ph