(The below “simple document” is found from a link here on Erfa’s website, or you can copy and paste the below to your Word. )

In addition to the prescription of the physician mentioning THYROID and the dosage requested (30 mg or 60 mg or 125 mg), we will also need this document to be filled in and given to the pharmacist for the delivery of THYROID

DECLARATION of THE PHYSICIAN

This declaration is intended to the pharmacist for the delivery of a product, for which no “Market Authorization” exists at the moment.

Name and Forename of the prescribing physician: ………….………………………….………

Address:          Street and number……………………………………………………………….

City and postcode……………………………………………………….……….

Country……………………………..

Phone number: ………………………………            Stamp:

Fax number:                 ………………………………

E-mail address: ………………………………

National identification number:   ………………

The Undersigned Physician declares that:

1/ His/her patient (Name and Forename of the Patient:………………………………………) cannot be treated adequately with the products currently available in the country and that for the treatment of his/her patient, the product (Mention denomination, form, dosage and all relevant information relevant for the pharmacist)

………………………………………………………………………………………………….…………………………………………………………………………………………………..

is necessary for a period of …………….. ………………(Mention period), with a posology of

……………………………………………………………………………………………….….(Mention posology)

2/ He/she is aware that currently, in the concerned country, no Market Authorization is granted to this product and that at this stage, the product did not pass through quality, efficacy and safety tests and that he/she did explain this situation to the patient or representative(s) of the patient*.

* Please note that the product THYROID exists for a very long time now in Canada where it demonstrated all evidence of quality, efficacy and safety and obtained a Market Authorization.

3/ He/she will inform immediately, without mentioning the name of the concerned patient in order to protect his/her private life, the Pharmacovigilance Center of the country where the product has to be delivered, in case of all undesirable side-effect (obviously linked to the product here delivered) occurring during the treatment.

Date and signature of the Physician,

………………………………………

……………………………………