Order form

For safety reasons and to prevent distribution errors Meerburg Pharmacy strongly recommends you to use this electronic order form. Please do not FAX this order form. We have a special fax form Print out and fax fax order form

Step 1: Please check if you meet all of the requirements.

1. Your specialist must declare to be familiar with the indications, the administration and dosage, contra-indications, precautions, drug interactions and side effects and has informed the patient that Crestor® is not on the approved list (informed consent);
2. Your doctor must declare that he/she is aware that Crestor® is not approved but that no other effective treatment is available domestically (no approved alternatives);

This doctor's declaration must show your name and date of birth.

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3. The importer (you) must declare that you import Crestor® for the patient's own use (max. 3-month supply) and provide the name and address of the qualified doctor (licensed in the country of import), responsible for evaluation of the treatment with Crestor® (patient's declaration);

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4. You have a prescription from your treating doctor.

This prescription must show your name and date of birth.

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Please double-check if all the documents show patient's name and date of birth.

Send the required information to:

fax number 00 31205248322

00 is the international dial prefix (+)

(USA: toll free: 1 877 839 2664)

Step 2: Please check the requested number of days.

FedEx International Priority (1-2 days + clearance time) 1.00 EUR ~ 1.07 US$ (as for March 2003)

Step 3: Please provide your personal information.

Step 4 Waiver.

• I realise that Crestor® is a registered medication in the Netherlands (European Union) but is not on the approved list in my country.

• I have a prescription from a qualified and competent doctor, who is acquainted with the extended information on Crestor® and has advised and informed me about the alternatives, the dosage and administration, contra-indications, precautions, drug interactions and side effects.

• I understand that the dispensed Crestor ® packages are conditioned for use in the Netherlands. Meerburg Pharmacy adds a package leaflet in English.

• I understand and realise that Meerburg Pharmacy has no knowledge of my medical record and condition so that Meerburg Pharmacy cannot be held responsible for my treatment, drug interactions of contra-indications and surveillance of my medication.

• I declare that I have read and understood the package leaflet.

Therapeutical indications:

• I understand that Crestor®’s approved indication in the Netherlands is for the treatment of patients with primary hypercholesterolaemia (type IIa including heterozygous familiar form) or mixed dyslipidaemia (type IIb) as am adjunct to diet when response to diet and exercise is inadequate.

• I understand that the recommended starting dose of Crestor® for adults is 10 mg (once daily) and that the majority of patients are controlled at this dose. A dose adjustment to 20mg can be made after 4 weeks, if necessary.

• I understand that Crestor 40mg should only be used in patients with severe hypercholesterolaemia who do not achieve their treatment goal on 20mg.

Contra-indications:

• I understand that I must not use Crestor® if I am hypersensitive (allergic) to rosuvastatin or any of the other ingredients of Crestor ® tablet listed in the package leaflet.

• I understand that I must not use Crestor® with active liver disease including unexplained, persistant elevation of serum transaminases and any serum transaminase elevation exceeding 3 x the upper limit of normal.

• I understand that I must not use Crestor® if I suffer from myopathy (a muscle disease).

• I understand that I must not use Crestor® if I receive cyclosporin.

Special warnings and precautions:

• I understand that Crestor® should be used with caution if I consume excessive quantities of alcohol and/or have a history of liver disease and/or a kidney disease.

• I understand that it is recommended that liver function test be carried out prior to, and 3 month following the initiation of my treatment with Crestor®.

• I understand that I should report to my doctor inexplicable muscle pain or weakness immediately, particularly if associated with malaise of fever.

• I understand that if I should inform my doctor of any problems of diseases I am suffering from or am treated for.

• I understand that if I use medicinal products called gemfibrozil, cyclosporin, nicotinic acid, azole antifungals, protease inhibitors, and macrolide antibiotics, I should not use Crestor®.

• I understand that proteinuria has been observed in patients with higher doses of Crestor®.

• I understand the during the use of Crestor® I must not become pregnant or breast-feed.

Interactions with other medicines:

• I understand Crestor® influences the effect of different medicines and that I should inform my doctor if I am taking, or have recently taken, any other medicines, even those obtained without a prescription

• I understand that in particular, the effect of the following medicines may be changed by Crestor® and that their dose may need to be adjusted by my doctor:

  • vitamin K antagonists: warfarin, acecoumarol, etc.:Appropriate monitoring of INR is desirable during initiation of treatment, dosage-up titration, down titration and discontinuation.

  • oral contraceptive: Concomittant use of Crestor results in an increased plasma lever of the hormones. This should be considered when selecting oral contraceptive doses.

• I understand that in particular, the effect of the following medicines may influence the plasma level of Crestor®:

  • gemfibrozil

  • cyclosporin

  • antacid. Take the antacid at least 2 hours after Crestor®

  • erythromycin

Side effects:

• I understand that like all medicines, Crestor® can have side effects.

• I understand that the most common side effects (frequency 1-10%) are headache, dizziness, constipation, nausea, abdominal pain, myalgia, and asthenia.

• I understand that other rare (0,01-0,1%) reported side effects are myopathy (a muscle disease). If this adverse effects should occur I will contact my doctor immediately.

• I understand that if the incidence of adverse drug reactions tend to increase with increasing dose.

• I understand that if I suffer from any other adverse effect not mentioned in the package leaflet, I will inform my doctor or pharmacist.

• I hereby release Meerburg Pharmacy and all of her employees and contractors including doctors from all liability associated with my Crestor® prescription and/or the use of Crestor®. I understand that no doctor, pharmacist, nurse or administrative personnel can guarantee that Crestor®, even if prescribed, will provide the results I seek. I hereby agree to have answered truthfully all of the questions. I also understand that if I fail in any way to furnish my doctor with my complete and accurate medical history or become aware of any changes in the future which I have not notified Meerburg Pharmacy of then I cannot hold them responsible for any adverse effects I may suffer.
• I am fully aware that it is my responsibility to have an annual physical examination, including any suggested laboratory tests, to ensure that I have no disease, which might make Crestor® inappropriate for me. I further agree to notify all doctors, whose present care I am currently under or any doctor whom I may engage in the future, of my decision to use Crestor® so they may advise to continue or discontinue the use of this medication.
• If approved, I irrevocably appoint Meerburg Pharmacy to be my agent and have my prescription and any refills filled by by Meerburg Apotheek or a Netherlands Pharmacy of its choice.
• I understand that when I buy goods in another country I become the importer and my personal medication may be subject to the payment of duty as well as to whatever rules and regulations govern the importation.
• I understand that Meerburg Pharmacy is unable to accept returns or issue refunds for any orders due to the fact that this is a prescription medication.
• I understand that my prescription has to be approved and confirmed by Meerburg Pharmacy, if not approved there is no charge.

• My medication will be shipped by FedEx International Priority, UPS or DHL. This service will include help with customs clearance systems and real-time tracking information.
• Meerburg Pharmacy will add a copy of my prescription and my doctors declaration with the shipment to facilitate importation. I understand that custom clearance cannot be guaranteed by Meerburg Pharmacy.

Step 5 Print this page now for information and reference.

Step 6 Transmit your order to Meerburg Pharmacy.

No Yes I have truthfully filled in this form and agree to the above

(click on transmit button)

After transmitting your order, wait (up to 2 minutes) for the automatic generated confirmation page.

If you get an error, you may select the standard form below as your browser might not support 128 bit secure data transmission.

Crestor® standard order form standard security

Step 7 Please do not forget to send us the required documents

• your prescription

• declaration of your treating doctor

TO: (FAX +31 205248322)

(EU: FAX 0031 205248322)

(N-America: FAX 011 31 205248322)

(USA: toll free: 1 877 839 2664)

(Australia: FAX 0011 31 205248322)

After receiving your order AND APPROVAL BY THE PHARMACY we will send you a confirmation by e-mail with the FedEx Air Waybill number for reference.

If you have any questions about your order we prefer you to contact us by email ). Phone Meerburg Pharmacy (+31 104136727) (office hours GMT+1). Voice mail messages (USA: 1 877 839 2664)

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