EpiPen Herinnering Programma

Oranjelaan 91 3311 DJ Dordrecht tel. 078 639 03 56 fax. 078 639 02 43 E-mail: info@anafylaxis.net

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ANAFYLAXIE
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FREE!! IMPORTANT EXPIRATION DATE REMINDER PROGRAM

Register here for the free expiry date reminder programme! Specially for owners of an adrenaline auto injector like the EpiPEn® or Anapen®.

This service is free and we will do our utmost to help you in the management of your severe allergy. However You are responsible for the timely replacement of your adrenaline auto injector, like the EpiPen®.
We hope you will never be exposed to the substance you are allergic to. But as avoidance of allergens is very hard and almost impossible, it is necessary that you always carry your adrenaline auto injector with you.
That is why we have started with this reminder programme.

The epinephrine in the auto injector, like the EpiPen®, has just like any other medication, an expiry date. This means it will deteriorate some day. The expiry date on the device is on the safe side, but after this date you must not use it anymore.

By registering all your adrenaline auto-injectors, like the EpiPEn®, you are being warned in time to get a new auto-injector. This way you will have time enough to ask a new prescription from your doctor and go to the pharmacy to order a new adrenaline auto-injector. This way ensures the availability of a non expired adrenaline auto-injector.

Registrering is voluntair and free! Complete the form below and click on the submit button. Be sure to register every adrenaline auto injector, to get a timely e-mail alert.

Complete the data in the form below. Put in the data of the person who has been prescribed the adrenaline auto injector.
The data will be filled and managed by the Nederlands Anafylaxis Netwerk. The data supplied will ony be used for the purpose of allerting the user that the expiry date is due.

First Name
Family Name
Address
Postal code
City
Country
Date of Birth	Jaar:
Gender	malen female
E-mail address 1 E-mail address 2

Date supplied (when known) (month/ year)			Expiry Date (Month/ Year)
1e adrenaline auto-injector		expires on
2e adrenaline auto-injector		expires on
3e adrenaline auto-injector		expires on
4e adrenaline auto-injector		expires on
5e adrenaline auto-injector		expires on
6e adrenaline auto-injector		expires on
7e adrenaline auto-injector		expires on

Specialism of the doctorwho prescribed the injector
If different, please state which specialism

Which caused the anaphylaxis? (one or more causes possible)
Food, i.e.
Insectpoison,i.e.
Latex
Medication,i.e.
Different,i.e

Het Nederlands Anafylaxis Netwerk will never pass on your personal data to others, unless requested by yourself. You, yourself, will stay responsible for the timely replacement of the adrenaline auto-injector!

EpiPen on Americkan Television

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Explanation of Allergy for Children (Still in Dutch)

The FORUM of the Nederlands Anafylaxis Netwerk

The Epinephrine Mate, A Special designed carrier for the EpiPen®

An automatic expiry date reminder of your epinefrine-auto-injector, like the EpiPen®

The Action plan in different languages.

An English site with a lot of information on insect allergy.