CONFIDENTIAL

Application to prescribe under

Section 59E of the Poisons Act 1971
DEPARTMENT of All correspondence marked “Confidential” to
HEALTH and HUMAN The Secretary Pharmaceutical Services, DHHS, GPO Box 125 HOBART TAS 7001
SERVICES For further information contact: Tel. (03) 6233 2064 Fax. (03) 6233 3904
TICK DATA AS APPROPRIATE PLEASE USE BLOCK LETTERS

I Dr

Postcode:

Telephone number: Fax number:

Make application for
PATIENT'S NAME
(FAMILY NAME) (GIVEN)
Patient's Address:
(Full Residential Address)
Postcode:
Previous address if any
aka

Date of Birth:   Gender: Male / Female

(circle appropriate one)

Usual Occupation: Working:
Yes
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:

The clinical use of this medication at this particular dose has been supported by:

Name of Specialist:

Please attached the relevant specialist reports

The patient is / is not in my opinion drug dependent Grounds for drug dependency: Iatrogenic
Illicit

IVDU Y / N (circle)
Patient has been previously treated by:

Patient has received opioid pharmacotherapy as part of any opioid pharmacotherapy program YES / NO (circle)
And I have reason to believe that this person:
Has a history of drug seeking behaviour

Is exhibiting drug seeking behaviour

Has used a notifiable or schedule 8 substances contrary to prescribing instructions and

route of administration. (e.g. escalation of dose, injecting medication)
that none of the above applies to this patient
Drugs Involved (please specify)………………………………………………………..

Signature of medical practitioner: Date: