PRIMARY HEALTH CARE - REMOTE
NON-S100 PHARMACY ITEMS REQUEST - FORM
This form is for use by Pharmacy staff to request non S100 Medicines against client prescriptions from Hospital
Pharmacies, including those for inclusion in Dose Administration Aids. Fax to the Hospital Pharmacy with a copy faxed to
the health centre.
Note: Health centre staff should be aware that local arrangements exist to ensure that non S100 Medicines are provided
by Regional Hospital Pharmacies to S100 contracted pharmacies for inclusion in Dose Administration Aids.
Reference: Pharmacy Ordering, Regional Hospital Pharmacies, S100 Pharmacy Arrangements.
DATE:
Please tick ( √ )
TO:
Alice Springs Hospital
Fax No:
08 8951 7766
Gove District Hospital
Fax No:
08 8987 2089
Katherine District Hospital
Fax No:
08 8973 9236
Royal Darwin Hospital
Fax No:
08 8922 8499
CC:
HEALTH CENTRE
Fax No:
FROM:
S100 PHARMACY
Phone No:
Fax No:
NON- S100 ITEM/S REQUESTED FROM HOSPITAL PHARMACY:
Client Prescription Form/s attached
Client’ Name
Send to
HRN / DOB
Developed by: Quality & Safety Team
Endorsed by: Remote Health Pharmacy Group
Release Date: January 2012
Medicines / Comments
Page 1
Reviewed: July 15
Next Review: July 2018
Urgent
Health
Centre
S100
Pharmacy