FORM TO BE USED IF AGENT COLLECTS MEDICATION FROM PHARMACY FOR PATIENT
I understand that ……………………..(insert pharmacy name) is collecting information for the purposes of monitoring
practices of unapproved pharmacies in supplying medications under the Pharmaceutical Benefits Scheme and the
charges made for the supply of medications at approved pharmacies. The pharmacy intends to provide information
about these issues to regulatory agencies for consideration and action.
I (the agent and the patient) understand that I am under no obligation to provide personal information to the
pharmacy and that I do not have to sign this consent form. I can withdraw my consent to disclosure at any time prior
to the disclosure being made. If I do decide to withdraw my consent to any of the disclosures that I have authorised
on this form, I will notify the pharmacy.
CONSENT OF PATIENT TO COLLECTION AND DISCLOSURE
I:
(patient name)
OF:
(patient address)
authorise the Guild to collect and disclose the personal information entered on this form by me and/or my agent and
copies of any attachments to this form to:
 Department of Health and Ageing;
 Department of Human Services (Medicare Australia);
 Australian Health Practitioner Regulation Agency;
 The relevant state/territory authority responsible for registering pharmacy premises in Australia; and
 The Pharmacy Guild of Australia.
INFORMATION ABOUT SUPPLY OF MEDICATION TO BE COMPLETED BY AGENT
ON
(date)
I PRESENTED THE PATIENT'S SCRIPT TO:
(pharmacy name)
OF:
(pharmacy address)
FOR SUPPLY OF:
(product name)
I RECEIVED THE MEDICATION FROM:
(location – if same as above, write “as above”)
AFTER WAITING FOR:
(time taken to dispense script)
AND IT WAS LABELLED AS FOLLOWS:
(e.g. dosage instructions, pharmacy details etc.)
ANY COMMENTS MADE BY STAFF AT THE PHARMACY ABOUT THE SUPPLY:
I SIGNED FOR THE PRESCRIPTION:

Yes

No
A REPEAT/S WAS ISSUED:

Yes

No
THERE WAS A PRF STICKER ATTACHED:

Yes

No
I WAS ISSUED A RECEIPT:

Yes

No
DATE AND DETAILS ON THE RECEIPT:
AMOUNT PAID:
YOUR NAME (PRINTED)
YOUR SIGNATURE
YOUR ADDRESS:
TODAY’S DATE:
BY COMPLETING AND SIGNING THIS FORM THE AGENT CONSENTS TO HIS/HER PERSONAL INFORMATION BEING DISCLOSED TO THE ABOVE AGENCIES.
I HAVE ATTACHED:
COPY OF REPEAT/S (IF ISSUED):

Yes

No
PRF STICKER:

Yes

No
RECEIPT (ORIGINAL):

Yes

No
COPY OF LABEL ON MEDICATION:

Yes

No