CONFIDENTIAL

Application to prescribe under Section 59E of the Poisons Act 1971	

I, Dr      <DrName>	
of	<DrAddress>			                                                                                        	
Telephone number:  	<UsrPhone>		Fax number: <UsrFax>	
Make application for:

PATIENT'S NAME :  <PtSurname>  , <PtFirstName>
	
Patient's Address:  	<PtAddress>	
AKA:	   <PtPrefName>  	Previous Address: 	
Date of Birth:       <PtDoB>	   Gender: <PtSex>		
Usual Occupation:  <PtOccupation>       Working:   r Yes      r No	
To prescribe the following schedule 8 opioids:   	
At the following dose:    	
The clinical grounds/condition for which this medication is required are:   
	
Other medications being concurrently prescribed:   <CurrentRx>	
The clinical use of this medication at this particular dose has been supported by:  

Name of Specialist:    

Please attach the relevant specialist reports	
The patient in my opinion     is   o      is not  o  drug dependent 

Grounds for drug dependency:     Latrogenic      o    Illicit       o            IVDU       Yes o 	 No o   	
Patient has been previously treated by:  
Patient has received opioid pharmacotherapy as part of any opioid pharmacotherapy program               Yes  o    No o	
And I have reason to believe that this person:

            	r Has a history of drug seeking behaviour                             
             	r Is exhibiting drug seeking behaviour 
                  	r Has used a notifiable or schedule 8 substances contrary to prescribing instructions and
	       route of administration. (e.g. escalation of dose, injecting medication)                              
               	r that none of the above applies to this patient
Drug(s) involved:    (Please specify)  ****	

Signature of medical practitioner:							Date: <Date>	
All correspondence to be marked “Confidential” and sent to:
The Secretary, Pharmaceutical Services, DHHS, GPO Box 125 HOBART TAS  7001
For further information contact:  (03) 6233 2064 Fax. (03) 6233 3904