CONFIDENTIAL

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

I, Dr <DrName>	
of <DrAddress>			                                                                                        	
Telephone number:  <UsrPhone>	Fax number: <UsrFax>	
Certify that:

Patient's name: <PtSurname>  , <PtFirstName>
	
Patient's address:  	<PtAddress>	
AKA:	   <PtPrefName>	
Date of Birth:       <PtDoB>	 Gender: <PtSex>		
Usual Occupation: <PtOccupation>       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 for whom I have prescribed or previously prescribed (select all that apply):>	
Further I also believe that this person is: <I believe 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