FAX YOUR ORDER TO: 0800 100 131
Please contact the Ministry of Health on 0800 353 2425 or 06 349 1987 for all enquiries.
ORDER FORM For:
Controlled Drug Prescription Form
H572
Controlled Drug Practitioners Supply
Order Pad
Controlled Drug Prescription Form
with Methadone Information preprinted
H571
Controlled Drug Hospital Bulk Supply
Order
H590
Max 4 Pads per
Provider
Max 2 Pads per
Provider
Max 2 Pads per
Provider
H572M
Pad of 10 Triplicate pages
Pad of 10 Triplicate pages
Pad of 10 Quadruplicate
pages
(unless authorised
Addiction Services
dispensary i.e.
CADS)
Max 10 Pads
per Institute
Pad of 10 Triplicate pages
For monitoring and recording purposes the Ministry encourage small frequent orders. Please complete each
line order per provider within your practice.
All fields in bold print are mandatory to assist with completion of orders.
Practice Name:
Provider Name
Medical
Council
Number
Please Note: H590 Pads
Hospital or Facility name
and address is required
Physical Delivery Address (Please Print):
Provider or Practice
Street Address
Suburb
Town / City
Post Code
Name of requestor
Contact Phone Number
Date of Order
Signature
Ministry of Health Use Only:
Date Processed:
Serial Numbers:
H572
H572M
H571
H590