Order form

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 lung specialist must have thorough experience in treatment with anticholinergics like Spiriva ® and declares to be familiar with the indications, the administration and dosage, contra-indications, precautions, drug interactions and side effects and has informed the patient that Spiriva® is not on the approved list (informed consent);
2. Your doctor must declare that he/she is aware that Spiriva® 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 Spiriva® 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 Spiriva® (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

(USA: toll free: 1 877 839 2664)

00 is the international dial prefix (+)

Step 2: Please check the requested number of days.

FedEx International Priority (1-2 days + clearance time) 1.00 EUR ~ 0.95 USD (as for June 2002)

Step 3: Please provide your personal information.

Step 4 Waiver.

• I realize that Spiriva® 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 lung doctor, who is acquainted with the extended information on Spiriva® 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 Spiriva ® package are conditioned for use in the Netherlands and are not yet available with an approved package leaflet in English.

• I understand that Meerburg Pharmacy can only provide a non-official translation in English from the instructions for proper use of Spiriva® and the cleaning instructions of the HandiHaler inhalation device.

• I understand and realize 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.

Therapeutical indications:

• I understand that Spiriva®’s approved indication in the Netherlands is for the maintenance treatment of patients with Chronic Obstructive Pulmonary Disease - COPD.

• I understand that Spiriva® is not a cure for COPD or emphysema.

• I understand that Spiriva® must be inhaled using a special device (HandiHaler) only once daily, each day and always at the same time of day.

Contra-indications:

• I understand that I must not use Spiriva® if I am allergic to tiotropiumbromid, atropin, or similar substances like ipratropium (Atrovent ®) or oxitropium, or to lactose.

Special warnings and precautions:

• I understand that Spiriva® cannot be used as a rescue therapy of acute episodes of brochospasms.

• I understand that after the administration of Spiriva acute allergic reactions might occur.

• I understand that like other anticholinergic medication it must be used with extreme care if I suffer from glaucoma, prostate problems, or urinary obstruction. If any of these symptoms should develop I must stop the use of Spiriva immediately and consult a doctor.

• I understand that inhaled medicines might cause inhalation-induced bronchospasms.

• I understand that if I suffer from renal insufficiency (creatinin clearance <50ml/min) I should not use Spiriva®.

• I understand that I must avoid letting the inhalation powder come into contact with the eyes as this might cause glaucoma, red eye, pain or unpleasant feeling in the eye, blur and other visual problems. If symptoms of glaucoma should develop I must stop the use of Spiriva immediately and consult a doctor.

• I understand that I must not use Spiriva more frequent than once in 24 hours.

• I understand that the dry mouth that is related to the use of anticholinergics might be related to the development of caries.

Interactions with other medicines:

• I understand that although no formal studies about interactions are available Spiriva® seems to be safe to use in combination with sympaticomimetics, methylxanthines, and oral and inhaled corticosteroids, used in the treatment of COPD.

• I understand that Spiriva® is not investigated in combination with other anticholinerics (such as Atrovent)®). It is advised not to use it in combination.

Side effects:

• I understand that long term safety studies are not available yet. The most reported side effect (1 out of 7 patients) in a one year study was dry mouth, usually mild, and often disappearing 3-5 weeks after the prolonged use of Spiriva®.

• I understand that other reported side effects are obstipation, monoliasis, sinusitus, faryngitis (1-10 out of 100) and allergic reactions, tachycardia, retention of urine, and prostate/urine flow difficulties (1-10 out of 1000). If any of these adverse effects should occur I will stop the use of Spiriva® and contact my doctor immediately.

• I understand that if I suffer from any other adverse effect I will stop the use of Spiriva® and contact my doctor immediately.

• I hereby release Meerburg Pharmacy and all of her employees and contractors including doctors from all liability associated with my Spiriva® prescription and/or the use of Spiriva®. I understand that no doctor, pharmacist, nurse or administrative personnel can guarantee that Spiriva®, 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 Spiriva® 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 Spiriva® 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)

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

• your prescription

• declaration of your treating doctor

We keep your doctor's declaration and prescription on file for your refill orders. You do not need to fax them again.

TO: (FAX +31 205248322)

(EUR: FAX 0031 205248322)

(N-America: FAX 011 31 205248322)

(USA: toll free: 1 877 839 2664)

(Australia: FAX 0011 31 104333609)

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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