Metoject® Home Care & Support Services

All Metoject® patients can access either or both Metoject® Homecare Services in Ireland (Free of charge)

Nurse to train patients’ in their home & at their convenience.

A sharps waste disposal service to discard used Metoject® PENS is available. Sharp bins are delivered to and from the patients’ home (carried out by our licensed contractor).

For a replacement sharps bin please contact Fannin on 01- 290 7000/7069. Please note that only used Metoject Pens can be placed in the sharps bin provided.

Register My Patient For Home Services

I am a Dr / Nurse

CONFIDENTIAL

Metoject® Pen Homecare - HCP Referral Form

Metoject® Pen Homecare Pop-Up Patient Referral Form - CONFIDENTIAL

Please select which option(s) you require: *

A nurse to train the patient in self-administration either at their home or a nominated health care facility

A sharps bin for waste disposal of used pens

SECTION A. PATIENT INFORMATION

Patients First Name *

Patients Surname *

Patients Home Address *

Patients Home Address

Address 1

Address 2

City

County

Postcode/EirCode

Patients Date of Birth *

Patients Phone Number *

Mobile or Landline

Has the patient been prescribed Metoject Pen? *

Yes

Patient Allergies

Patient's Pharmacy Name

SECTION B. REFERRING CLINICIAN INFORMATION

Date *

Hospital *

Department *

Referring Hospital Consultant *

Registered By *

Department Phone Number *

Mobile or Landline Number

Email Address *

SECTION C. INDICATION & PRESCRIPTION INFORMATION

Indication *

Prescription - Please indicate the presentation of Metoject® 50mg/ml PEN prescribed *

7.5mg

10mg

15mg

20mg

25mg

Please note these are the only available presentations

Is the patient currently on Oral Methotrexate? *

Yes

If ‘Yes’, please indicate the day the Oral Methotrexate medication is taken *

Mon

Tue

Wed

Thu

Fri

Sat

Sun

Frequency *

Is the patient currently on any other medication?

Yes

If yes, please list all medications *

I have discussed the Metoject® PEN Homecare Service with the patient and, they have given their consent to receive the service. *

(Patient Agrees)

Patient agrees for their personal data to be sent to our approved licensed Metoject® PEN Homecare service providers: Point of Care (nurse training) and/or, SRCL (sharps waste disposal). *

(Patient Agrees)

If you are human, leave this field blank.

All data held by Fannin Limited and their approved license contractors, is for the sole purpose of these Metoject® services
and, is in accordance with the Data Protection Act 1998 and 2003.

Pharma Division, Fannin Limited,
Fannin House, South County Business Park, Leopardstown, Dublin 18
Tel: 01 290 7000/7069 Fax: 01 290 7216 Email: metoject@fannin.eu

I am a Pharmacist

CONFIDENTIAL

Metoject® Pen Homecare - Retail Pharmacy Patient Referral Form

Metoject® Pen Homecare Retail Pharmacy Referral Form - CONFIDENTIAL

Please select which option(s) you require: *

A nurse to train the patient in self-administration at their home

A sharps bin for waste disposal of used pens

SECTION A. PATIENT INFORMATION

Patients First Name *

Patients Surname *

Patients Home Address *

Patients Home Address

Address 1

Address 2

City

County

Postcode/EirCode

Patients Date of Birth *

Patients Phone Number *

Mobile or Landline

Has the patient been prescribed Metoject Pen? *

Yes

Patient Allergies

SECTION B. REFERRAL INFORMATION

Date *

Referring Hospital Consultant *

Hospital *

Retail Pharmacy Name *

Pharmacist Name *

Pharmacy Address *

Pharmacy Address

Address 1

Address 2

City

County

Postcode/EirCode

Pharmacy Phone Number *

Mobile or Landline Number

Pharmacy Email Address *

SECTION C. INDICATION & PRESCRIPTION INFORMATION

Diagnosis *

Is the patient currently on Oral Methotrexate? *

Yes

If ‘Yes’, please indicate the day the Oral Methotrexate medication is taken *

Mon

Tue

Wed

Thu

Fri

Sat

Sun

Prescription - Please indicate the presentation of Metoject® 50mg/ml PEN prescribed *

7.5mg

10mg

15mg

20mg

25mg

Please note these are the only available presentations

Frequency *

Is the patient currently on any other medication?

Yes

If yes, please list all medications *

I have discussed the Metoject® PEN Homecare Service with the patient and, they have given their consent to receive the service. *

(Patient Agrees)

Patient agrees for their personal data to be sent to our approved licensed Metoject® PEN Homecare service providers: Point of Care (nurse training) and/or, SRCL (sharps waste disposal). *

(Patient Agrees)

If you are human, leave this field blank.

All data held by Fannin Limited and their approved license contractors, is for the sole purpose of these Metoject® services
and, is in accordance with the Data Protection Act 1998 and 2003.

Pharma Division, Fannin Limited,
Fannin House, South County Business Park, Leopardstown, Dublin 18
Tel: 01 290 7000/7069 Fax: 01 290 7216 Email: metoject@fannin.eu

Covid-19: All nurses attending patients in their home for the purposes of Metoject training strictly adhere to the policy and guidelines as set out by the HPSC (Health Protection Surveillance Centre).