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CONFIDENTIAL

Metoject® Pen Homecare – Self-Referral Form (For Patients)

Starting Metoject? We’re here to help.

Fannin’s homecare service is designed to make your treatment as smooth and comfortable as possible.

A nurse can visit your home to show you how to use your Metoject® Pen.

We’ll collect your used pens and sharps bin safely.

Just fill in the form below to get started.

Metoject® Pen Homecare Self Referral For Patients
What support would you like? (Tick all that apply) *

SECTION A. YOUR DETAILS

Patients Home Address *
Patients Home Address
Address 1
Address 2
City
County
Postcode/EirCode
Mobile or Landline

SECTION B. YOUR CLINIC INFORMATION

SECTION C. ABOUT YOUR METOJECT TREATMENT

Which Metoject® Pen strength have you been prescribed?
Please select one
Have you taken methotrexate tablets before?
If yes, which day do/did you take the tablets? *
Are you currently taking any other medications?
I agree for to my 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). *

 

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