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,<<Doctor:Name>>	

of: <<Doctor:Full Address>>											

Telephone number:<<Doctor:Phone>>					Fax number: <<Doctor:Fax>>	
Certify that:
	
PATIENT'S NAME: <<Patient Demographics:Full Name>>                         AKA <<Patient Demographics:First Name>>	

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

Drugs involved and details - specify:
<<Drugs involved and details (please specify)>>
	
Further I also believe that this person <<I believe this person is/is not drug dependent>> drug dependent
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: <<Drugs involved (select all that apply)>>
Other (specify): <<Other drugs involved (specify)>>	

Signature of medical practitioner:  					Date:<<Miscellaneous:Date>>	

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