CONFIDENTIAL	
	
Notification under Section 59B of the Poisons Act 1971
NOTIFICATION REQUIRED FOR DRUG SEEKING, MISUSE AND INAPPROPRIATE USE

DETAILS MUST BE COMPLETED LEGIBLY TO PREVENT DELAY
TICK DATA AS APPROPRIATE.   PLEASE USE BLOCK LETTERS	

I, <DrName>	

of: <UsrAddress>											

Telephone number: <UsrPhone>					Fax number: <UsrFax>	
Certify that:
	
PATIENT'S NAME: <PtFullName>                                                              AKA <PtPrefName>	

Patient's Address:
<PtAddress>
	
Date of Birth: <PtDoB>                                                                             Sex:    <PtSex>
	
Usual Occupation:<PtOccupation>                                                                     Working: <Is thehe patient is currently working?>
	
Is seeking
•	a notifiable restricted substance (e.g. benzodiazepines and Panadeine Forte®) namely:
<Patient is seeking a notifiable restricted substance, namely:>
•	or a Schedule 8 substance namely: 
<Patient is seeking a Schedule 8 substance, namely:>	
And I have reason to believe that this person for whom I have prescribed or previously prescribed:
<And I have reason to believe that this person for whom I have prescribed or previously prescribed:>

Drugs involved and details - specify:
<Drugs involved:>
	
Further I also believe that this person <I have reason to believe that this person:>
Grounds for drug dependency:<Grounds for drug dependency:>
Is the patient an Intravenous Drug User: <Is the patient an intravenous drug user?> 
Drug(s) involved: <Drug(s) involved:>
Other (specify): <Other drugs involved (specify):>

Signature of medical practitioner:  					Date:<TodaysDate>	

All correspondence to be marked “Confidential” and sent to:
Chief Pharmacist, Pharmaceutical Services Branch, Department of Health, GPO BOX 125, Hobart TAS 7001

For further information: Tel: (03) 6166 0400, Fax: (03) 6173 0820, Email: pharmserv@health.tas.gov.au