Patient Details	
First Name:	<PtFirstName>	Middle Name/s:	<PtMidName>	Surname:	<PtSurname>	
Date of Birth:	<PtDoB>	Gender (Male, Female, non-binary):	<PtSex>	
Residential Address:	<PtStreet>	
Suburb:	<PtCity>	State:	<PtState>	Postcode:	<PtPostcode>	
Please provide any additional information below:	

Parent/ Carer details (if patient under 18 years old)	
Parent/Carer 1 Full name:	<Parent/Carer 1 Full name>	Date of Birth:	<Parent/Carer 1 Date of Birth>	
Parent/Carer 2 Full name:	<Parent/Carer 2 Full name>	Date of Birth:	<Parent/Carer 2 Date of Birth>	

Prescriber Details	
Full Name:	<DrName>	
AHPRA Number:	<DrRegistrationNo>	Prescriber Number:	<DrPrescriberNo>	
Practice Address:	<Practice>, <DrStreet>, <DrCity>, <DrState>, <DrPostcode>	
Telephone:	<UsrPhone>	

Medication Details – Requested Schedule 8 Medicines	
Medicine Name	Directions for use (must include dose, frequency, and formulation)	
<Requested Schedule 8 Medicines Name>	<Directions for use (must include dose, frequency, and formulation)>	

Treatment Details	

	
I certify this patient satisfies the diagnostic criteria for opioid use disorder (DSM-5), and in my opinion, opioid 	

	
replacement therapy is required, and treatment will be provided in accordance with the relevant clinical guideline	

	
Drug(s) of Dependence – substance(s) contributing to the dependence:	<Drug(s) of Dependence – substance(s) contributing to the dependence:>	
Name of dosing site(s):	<Name of dosing site(s):>

Declarations – please ‘x’ to notify or leave blank if not applicable  	

The patient in my opinion:	

Is drug dependent	

Grounds for drug dependency:	

Latrogenic	
	
Illicit	

Does the patient have current, or a history of 
intravenous drug use (IVDU):	

Yes, currently IVDU	

	

	

Yes, history of IVDU	

I have reason to believe the patient:	

Is exhibiting drug seeking behaviour	

	

	

Has a history of drug seeking behaviour	

The patient has previously received opioid replacement therapy as part of any treatment for opioid use disorder (DSM-5):	

Yes	

	

	

	

	
I acknowledge an application for authorisation to treat a person with Schedule 8 medicine(s) is a requirement of the Poisons Act 1971 and I have informed the patient I am required to seek authorisation for this medicine(s). 
I acknowledge that as part of the risk-informed assessment of my application the Secretary may seek further information relating to the medical history and treatment of the patient including a documented treatment plan. 
I acknowledge if an authority is granted it does not act as clinical endorsement for the treatment I am proposing. 
I also acknowledge in making this application I am asserting in my opinion as a registered health practitioner this treatment is clinically appropriate for this patient and will be provided in accordance with the relevant clinical guidelines.	
Signature of prescriber:		Date of application:	<TodaysDate>