Certificate of Medical Necessity

You must have a new doctor's letter every time you order along with the added sentence below
(one of 4 FDA required documents)

      USDA Permits Still Required!

_______________________________________

_______________________________________

_______________________________________

_______________________________________

_____________________________________  
Name Personal or Corporate & US/State Rx ID Number

_____________________________________  
Office Address & Phone & FAX Number

_______________________________
Date

RE: ____________________________________________________________

(Patientís Name)

To Whom It May Concern:

 

The above named patient has a history of Type __1 __2 diabetes mellitus and s/he has had significant __ hypoglycemia without adequate early warnings, __ allergy, __ glucose control, __ other ___________________________ problems when s/he uses any of the insulins available in the US, synthetic human or other synthetic insulin. Therefore, the use of the insulins still available and the US is contraindicated in this patient. The patient manifests the daily need for at least _____ units of insulin per day and requires at least ____ 1,000 Unit/10cc bottles of these insulins every six months.  The patient requires natural  bovine and or porcine insulin.

 

Projecting a patientís precise insulin needs is not possible. At this time, patient would need to use approximately ____ bottles of natural Neutral (R) every six months, and _____ bottles of natural Isophane (N) every 6 months, and ____ bottles of natural Lente (L)  every six months,  and ___ bottles of Protamine Zinc (nearest comparable for UL or PZI) every six months. If s/he does not use the specificied medications, the risk of significant and potentially life-threatening problems is markedly increased and other complications can occur. 

New sentence below:

Furthermore, I will report any adverse reactions in connection with these insulins to Wockhardt UK Limited/CP Pharmaceuticals Limited located at:

Ash Road North

Wrexham Industrial Estate

Wrexham LL139UF

United Kingdom

 

 

If there are any questions, please do not hesitate to contact this office.

 

Sincerely,

 

_______________________________________________

Doctor's Signature                                                       Title



USDA Import Permit, Doctorís Certificate of Medical Necessity, and Personal Certificate of personal use and 6 month supply