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