This form includes:
- patient eligibility checklist
- privacy notice and patient consent
- dosing details
- treating physician’s declaration
- reapplication checklist.
Life Saving Drugs Program – Pompe disease – Reapplication
We are working to improve this form, which currently does not display correctly in all web browsers. In the meantime, you can use the PDF version by:
- Saving the PDF to your hard drive and opening it with your PDF software. Right-click on the download link and select 'Save link as', then choose a destination on your device to save the file.
- You can then type into the fields before printing, signing and returning to us.
About this resource
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Form
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English
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