CONFIDENTIAL

Notification under Section 59B of the Poisons Act 1971
NOTIFICATION REQUIRED FOR DRUG SEEKING, MISUSE AND INAPPROPRIATE USE	

I, <<Doctor:Name>>	
of <<Doctor:Address>>			                                                                                        	
Telephone number: <<Doctor:Phone>>	Fax number: <<Doctor:Fax>>	
Certify that:

Patient's name: <<Patient Demographics:Surname>> , <<Patient Demographics:First Name>>	
Patient's address: <<Patient Demographics:Address>>	
AKA:	  **patient preferred name**	
Date of Birth: <<Patient Demographics:DOB>>	 Gender: <<Patient Demographics:Gender>>	
Usual occupation: <<Patient Demographics:Occupation>>      Working: <<Patient is currently working>> 	
Is seeking 
•	a notifiable restricted substance (e.g. benzodiazepines and Panadeine Forte) namely: ****
•	or a schedule 8 substance namely: ****	
And I have reason to believe that this person for whom I have prescribed or previously prescribed 
<<I have reason to believe that this person:>>	
Further I also believe that this person is: <<I believe that this person is: >>   
Grounds for drug dependency:  <<Grounds for drug dependency>>   IVDU <<IVDU>>	
Drug/s involved:  
<<Drug/s involved:>>                         
Other (specify)  ****	

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