Therapeutic Drugs Monitoring TDM 2018 Therapeutic Drugs Monitoring Scheme Application Form
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1 complete all sections below and return to LGC Standards Proficiency Testing by , fax or post. Returning customer Lab ID: TM Purchase order no.: (compulsory) TDM Distribution Schedule Samples for the main TDM scheme are sent three rounds at a time, four times a year (i.e. all Therapeutic Drugs samples apart from the Antibiotics; see page 4 for the Antibiotics distribution schedule). indicate the samples required on pages 2-5. Round Despatch Date Reporting Deadline TM Feb TM Jan 26 Mar TM Apr TM May TM Apr 25 Jun TM Jul TM Aug TM Jul 24 Sep TM Oct TM Nov TM Oct 07 Jan 2019 TM Feb 2019 For details on the technical specification of the scheme, please refer to the TDM Scheme Description. fill in your address details below: Send Test Materials to: Department: Company: Address: Town/City: Post/Zip Code: Country: Tel: Fax: Send Report Notifications to: # : Send Invoices to: Department: Company: Address: Town/City: Post/Zip Code: Country: Tel: Fax: VAT no: # An will be sent to this address to notify when the report is available to download from PORTAL, the online reporting system tdm@lgcgroup.com, Website: Page 1 of 5
2 Therapeutic Drugs tick the required samples in the grid below: Therapeutic Drugs Monitoring TD1 Therapeutic Drugs mixture Carbamazepine; CBZ-epoxide; Carbamazepine+CBZ-epoxide; Clonazepam; Lamotrigine; Phenytoin; Ethosuximide; Phenobarbitone; Primidone; Valproate; Caffeine; Digoxin; Lithium; Theophylline; Methotrexate; TD-Amikacin; TD-Gentamicin; TD-Tobramycin; TD-Vancomycin 3 x 5ml samples of lyophilised Other Therapeutic Drugs tick the required samples in the grid below: CN1 Clobazam; Norclobazam AE1 Anti-epileptic drugs mixture 1 AE2 Anti-epileptic drugs mixture 2 AE3* Anti-epileptic drugs 3 AE4* Anti-epileptic drugs 4 AE5* Anti-epileptic drugs 5 CRD Cardiac mixture Clobazam; Norclobazam; OH-oxcarbazepine; Gabapentin; Tiagabine; Levetiracetam; Pregabalin Topiramate; Vigabatrin; Felbamate; Zonisamide; Rufinamide; Lacosamide Retigabine (Ezogabine) Perampanel Brivaracetam Amiodarone; Desethylamiodarone; Flecainide 2 x 2ml samples of lyophilised 1 x 4ml sample of lyophilised 1 x 4ml sample of lyophilised The Anti-Inflammatory drugs in Serum samples are distributed as part of the main TDM distribution and are available quarterly, to be distributed in rounds TM172, TM175, TM178 and TM181. AM1* Analgesic mixture Ibuprofen; Diclofenac; Tramadol 2 x 5ml sample of lyophilised Drugs used for the Treatment of substance related disorders tick the required samples in the grid below: SA01 Drugs for the Treatment of substance related disorders 1 SA02 Drugs for the Treatment of substance related disorders 2 Buprenorphine; Norbuprenorphine Methadone; EDDP 2 x 2ml lyophilised human serum 2 x 2ml lyophilised human serum tdm@lgcgroup.com, Website: Page 2 of 5
3 Psychoactive Drugs The Psychoactive Drugs are distributed as part of the main TDM distribution (i.e. 3 rounds distributed 4 times a year). Samples PS01-04 are available monthly, whereas samples PS05 PS32 are available quarterly, in the rounds as indicated below. The 5ml lyophilised samples are prepared from newborn calf serum or. tick the required samples in the grids below: Samples distributed monthly Sample Target Analyte(s) Available Rounds PS01 Amitriptyline; Nortriptyline All rounds ( ) PS02 Imipramine; Desipramine All rounds ( ) PS03 Clomipramine; Norclomipramine All rounds ( ) PS04 Clozapine; Norclozapine All rounds ( ) Samples distributed quarterly tick Discounts per total no. of monthly sample types ordered 1-3: No discount 4: 20% discount Sample Target Analyte(s) Available Rounds PS05 Doxepin; Nordoxepin 172;175;178;181 PS06 Fluoxetine; Norfluoxetine 172;175;178;181 PS07 Fluphenazine 172;175;178;181 PS08 Sertraline; Norsertraline 172;175;178;181 PS09 Trimipramine; Nortrimipramine 172;175;178;181 PS10 Risperidone; HO-risperidone 172;175;178;181 PS11 Mirtazapine; Normirtazapine 172;175;178;181 PS12 Maprotiline; Normaprotiline 173;176;179;182 PS13 Thioridazine 173;176;179;182 PS14 Haloperidol 173;176;179;182 PS15 Olanzapine 173;176;179;182 PS16 Perphenazine 173;176;179;182 PS17 Quetiapine; Norquetiapine 173;176;179;182 PS18 Citalopram; Norcitalopram 173;176;179;182 PS19 Dothiepin; Northiaden 174;177;180;183 PS20 Venlafaxine; Norvenlafaxine 174;177;180;183 PS21 Paroxetine 174;177;180;183 PS22 Fluvoxamine 174;177;180;183 PS23 Zuclopenthixol 174;177;180;183 PS24 Amisulpride 174;177;180;183 PS25 Aripiprazole; Dehydroaripiprazole 174;177;180;183 PS26 Ziprasidone 172;175;178;181 PS27 Duloxetine 173;176;179;182 PS28 Escitalopram 174;177;180;183 PS29 Trazodone 172;175;178;181 PS30 Sulpiride 173;176;179;182 PS31* Chlorpromazine; Norchlorpromazine 174;177;180;183 PS32* Mianserin 172;175;178;181 tick Discounts per total no. of quarterly sample types ordered 1-5: No discount 6-10: 5% 11-15: 10% 16+: 15% tdm@lgcgroup.com, Website: Page 3 of 5
4 Psychostimulants The Psychostimulant samples are distributed as part of the main TDM distribution and are available quarterly, to be distributed in rounds TM173, TM176, TM179 and TM182. PST1* Psychostimulants Atomoxetine; Methylphenidate; Ritalinic acid 2 x 5ml lyophilised Smoking Related Drugs The Nicotine and Cotinine in Urine samples are distributed as part of the main TDM distribution and are available quarterly, to be distributed in rounds TM172, TM175, TM178 and TM181. NC01* Nicotine and Cotinine in Urine Nicotine; Cotinine 2 x 5ml lyophilised human urine Antibiotic Drugs Four 1ml liquid samples prepared from are available for analysis each month. tick the required samples in the grid below: Sample Target Analyte(s) Discounts AT01 AT02 AT03 AT07 Gentamicin; Vancomycin Tobramycin Amikacin Teicoplanin Total no. of sample types ordered: 1-2: No discount 3-4: 15% discount Antibiotics Distribution Schedule The Antibiotic Drugs samples are distributed monthly (i.e. separately from the main TDM distribution) on the following dates: Round Despatch Date Reporting Deadline AT Jan 25 Jan AT Feb 22 Feb AT Mar 22 Mar AT Apr 19 Apr AT May 24 May AT Jun 21 Jun AT Jul 19 Jul AT Aug 23 Aug AT Sep 20 Sep AT Oct 18 Oct AT Nov 22 Nov AT Dec 20 Dec tdm@lgcgroup.com, Website: Page 4 of 5
5 note: contact LGC Standards Proficiency Testing for prices. VAT is payable (at the prevailing rate) by all participants based in the UK and by those in the rest of the European Union if a VAT Registration Number is not provided. Participants will pay an additional fee to cover courier charges. contact LGC Standards Proficiency Testing for up-to-date charges. All courier charges set by LGC Standards Proficiency Testing do not include local import charges, taxes (etc.), which will be covered by the participant. Do not send remittance with this form, you will be invoiced subsequently for the full year s participation. No refunds will be given for failure to take part in any round of the proficiency testing scheme or for cancellation of rounds that have already been invoiced. LGC Standards Proficiency Testing reserves the right to not send samples or the report for previous samples to any participant that has not paid their subscriptions within the terms stated on the invoice. LGC Standards Proficiency Testing cannot guarantee the number of participants that will return results for any particular round. The prices stated are for reporting results and receiving reports electronically via PORTAL (internet reporting). If alternative data entry or reporting methods are required, further charges apply. contact LGC Standards Proficiency Testing for the current charges. Your participation will not be automatically renewed if we do not receive your order. ensure that you return this application form to LGC Standards Proficiency Testing in order to confirm your participation. The scheme reports the performance of U.K. participants who are involved in patient care to the National Quality Assurance Advisory Panels for Chemical Pathology and for Medical Microbiology. By signing this application form, you are agreeing to comply by LGC Standards' Standard Terms and Conditions for the Supply of Laboratory Quality Products and Services. LGC Standards would like to be able to contact you from time to time with information about the LGC Group, its activities, products and services. By completing and returning this form to us, you agree to your personal information being used by LGC Standards and other members of the LGC Group for the administration and provision of our products and services and for related marketing activities. You can change your marketing preferences at any time by ing askus@lgcgroup.com Signature Date tdm@lgcgroup.com, Website: Page 5 of 5
Therapeutic Drugs Monitoring TDM 2016 Therapeutic Drugs Monitoring Scheme Application Form
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