Order form

This order form is SSL secure if your Internet browser shows the "keylock" symbol and protects your personal information and credit card data.

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.

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 Ebixa® is not on the approved list (informed consent);
2. Your doctor must declare that he/she is aware that Ebixa® 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 Ebixa® 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 Ebixa® (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 tablets.

FedEx International Priority (1-2 days + clearance time) 1.00 EUR ~ 1.15 US$ (as for April 2003)

Step 3: Please provide your personal information.

Step 4 Waiver.

• I realise that Ebixa® 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 Ebixa® 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 Ebixa ® 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 Ebixa®’s approved indication in the Netherlands is for the treatment of patients with moderately severe to sever Alzheimer's disease.

• I understand that the recommended dose of Ebixa® for adults is 20 mg (2x 1 tablet) daily and that in order to reduce the side effects this dose is achieved gradually by a daily treatment scheme as indicated in the package leaflet.

Contra-indications:

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

Special warnings and precautions:

• I understand that if I have a history of epileptic seizures I should not use Ebixa ®.

• I understand that if I have recently experienced a myocardial infarction (heart attack), or if I am suffering from congestive heart failure or from uncontrolled hypertension, I should not use Ebixa ®.

• I understand that if I suffer from moderate or severe renal impairment, I should not use Ebixa®.

• I understand that if I use medicinal products called amantadine, ketamine, dextromethorphan and others NMDA-antagonists I should not use Ebixa®

• I understand that my doctor will tell me whether my illness allows me to drive and to use machines safely. Also I understand that Ebixa® may change my reactivity, making driving and operating machinery inappropriate.

• I understand that Ebixa® must not be used by children and adolescents under the age of 18 years.

• I understand that I should inform my doctor is I have recently changed or intend to change my diet substantially (e.g. from a normal diet to strict vegetarian diet).

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

Interactions with other medicines:

• I understand Ebixa® 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 Ebixa® and that their dose may need to be adjusted by my doctor:

  • amantadine, ketamine, dextromethorphan

  • dantrolene, baclofen

  • cimetidine, ranitidine, porocainamide, quinidine, quinine, nicotine

  • hydrochlorothiazide (or any combinations with hydrochlorothiazide)

  • anticholinergics (substances generally used to treat movement disorders or intestinal cramps)

  • anticonvulsants (substances generally used to prevent and relieve seizures)

  • barbiturates (substances generally used to induce sleep)

  • dopaminergic agonists (substances such as L-dopa, bromocriptine)

  • neuroleptics (substances used in the treatment of mental disorders).

• I understand that I should report the use of Ebixa® if I go into hospital.

Side effects:

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

• I understand that the most common side effects (frequency 2% and less) are hallucinations, confusion, dizziness, headache and tiredness.

• I understand that other (uncommon) reported side effects are anxiety, hypertonia (increased muscle tone) vomiting, bladder infections and increased sexual drive.

• I understand that if I have experienced epileptic seizures, there is a (slight) possibility that Ebixa® may increase the chances of one occurring.

• 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 Ebixa® prescription and/or the use of Ebixa®. I understand that no doctor, pharmacist, nurse or administrative personnel can guarantee that Ebixa®, 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 Ebixa® 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 Ebixa® 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. 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.

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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