FORM TO BE USED IF THE PATIENT COLLECTS MEDICATION FROM PHARMACY
I understand that the ……………………………..(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. This pharmacy intends to provide
information about these issues to regulatory agencies for consideration and action.
I 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 this pharmacy.
CONSENT
I:
(patient name)
OF:
(patient address)
authorise the pharmacy to collect and disclose the personal information entered on this form by me 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
ON
(date)
I PRESENTED MY 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:
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