CONFIDENTIAL

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

DETAILS MUST BE COMPLETED LEGIBLY TO PREVENT DELAY
TICK DATA AS APPROPRIATE.   PLEASE USE BLOCK LETTERS	

I, <<Doctor:Name>>	

of: <<Doctor:Full Address>>	

Telephone number: <<Doctor:Phone>>				Fax number: <<Doctor:Fax>>	
apply for authority to prescribe for:
	
PATIENT'S NAME: <<Patient Demographics:Full Name>>			              AKA <<Patient Demographics:First Name>>	

Patient's Address:
<<Patient Demographics:Full Address>>	
Date of Birth: <<Patient Demographics:DOB>>				                           Sex:   <<Patient Demographics:Gender>>	
Usual Occupation: <<Patient Demographics:Occupation>>			         Currently Working: <<Is the patient currently working?>>	
I have checked DORA regarding this patient within the last seven days:                <<DORA checked re: patient within last 7 days?>>	
To prescribe the following Schedule 8 opioids at the specified dose:
<<I prescribe following Sched 8 opiods at dosage >>

Indication for Schedule 8 opioids:
<<Indication for Schedule 8 opiods>>

ALL other medications concurrently prescribed (Current Patient Medication List attached):
<<Clinical Details:Medication List>>	
The clinical use of this medication at this particular dose has been supported by <<Clinical use of medication at this dose supported by>>

Please attach the relevant specialist reports.	
The patient <<Patient in my opinion is/is not drug dependent>> in my opinion drug dependent

Grounds for drug dependency: <<Grounds for drug dependency>> 

Is the patient an Intravenous Drug User:  <<Is the patient an intravenous drug user?>>	
Patient has been previously treated by: <<Patient has previously been treated by>> 

Patient has received opioid pharmacotherapy as part of any treatment for opioid substance use disorder:
<<Any previous opioid pharmacotheraphy treatment?>>	
And I have reason to believe this person:
<<I have reason to believe (select all that apply)>>

Drugs Involved (please specify):
<<Drugs involved (please specify)>>

Signature of medical practitioner:  						Date:<<Miscellaneous:Date>> 	

All correspondence to be marked “Confidential” and sent to:
Chief Pharmacist, Pharmaceutical Services Branch, Department of Health, GPO BOX 125, Hobart TAS 7001
For further information: Tel: (03) 6166 0400, Fax: (03) 6173 0820, Email: pharmserv@health.tas.gov.au