CONFIDENTIAL

 Section 59B of the Poisons Act 1971
NOTICE OF DRUG DEPENDENCY	

I, <DrName>	
of <RefAddress>				                                                                                        	
Telephone number: <DrPhone>	Fax number: <DrFax>	
a legally qualified medical practitioner, hereby give notice that the following is patient is suffering from drug dependency.	

Patient's name: <PtSurname>, <PtFirstName>

AKA: <PtPrefName>	
Patient's Address: <PtAddress>	
Date of Birth: <PtDoB>	 Gender: <PtSex>		
Usual Occupation: <PtOccupation>       Working: <Patient is currently working>	
Grounds for drug dependency: <Ground for drug dependency:>  IVDU <IVDU>	
Drug/s involved:     
<Drug/s involved:>
 Other (specify): ******
Drug source: <Drug source:>	

Signature of medical practitioner:							Date: <TodaysDate>
	
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