MEDICAL PRACTITIONER DECLARATION Doctors Certification: (Doctor must be recognised as a metabolic specialist Doctors declaration: by the Department of Health): Details of the person with IEM condition requiring I certify that the above mentioned person has a diagnosed review: IEM and has a requirement for a special diet to manage their condition. I agree to the collection of my information for First Name: the purpose of determining the patient’s eligibility. Surname: SELECT ONE: Date of Birth: I certify that the patient is compliant with diet, appointment and monitoring requirements. Gender: Male Female OR I certify that concern about this patient’s compliance Diagnosis: (please tick patient’s IEM condition) has been raised with them/their family. An action plan Dihydropteridine reductase (DHPR) deficiency to address this has been put in place. Hyperphenylalaninemia OR Phenylketonuria (PKU) I certify that I have no evidence that patient is currently on the PKU diet Medically prescribed diet required: (please tick as appropriate) Ongoing Preconception Pregnancy Name: Period of Dietary prescription: Signature: ____________________________________ Date: _______________________________________
Doctors Certification: (Doctor must be recognised as a metabolic specialist by the Department of Health): Details of the person with IEM condition requiring review: First Name: Surname: Date of Birth: Gender: Male Female Diagnosis: (please tick patient’s IEM condition) Dihydropteridine reductase (DHPR) deficiency Hyperphenylalaninemia Phenylketonuria (PKU) Medically prescribed diet required: (please tick as appropriate) Ongoing Preconception Pregnancy Period of Dietary prescription: MEDICAL PRACTITIONER DECLARATION Doctors declaration: I certify that the above mentioned person has a diagnosed IEM and has a requirement for a special diet to manage their condition. I agree to the collection of my information for the purpose of determining the patient’s eligibility. SELECT ONE: I certify that the patient is compliant with diet, appointment and monitoring requirements. OR I certify that concern about this patient’s compliance has been raised with them/their family. An action plan to address this has been put in place. OR I certify that I have no evidence that patient is currently on the PKU diet Name: Signature: ____________________________________ Date: _______________________________________
iem-programme-application-form-a.docx