Life Saving Drugs Program – Pompe disease – Reapplication

Treating physicians use this form to reapply each year for a patient to receive ongoing LSDP medication for Pompe disease.


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.

We aim to provide documents in an accessible format. If you're having problems using a document with your accessibility tools, please contact us for help.

Publication date:
Publication type:
Health sector

This form includes:

  • patient eligibility checklist
  • privacy notice and patient consent
  • dosing details
  • treating physician’s declaration
  • reapplication checklist.

Help us improve

If you would like a response please use the enquiries form instead.