Patient Details	
First Name:	<<Patient Demographics:First Name>>	Middle Name/s:	<<Patient Demographics:Middle Name>>	Surname:	<<Patient Demographics:Surname>>	
Date of Birth:	<<Patient Demographics:DOB>>	Gender (Male, Female, non-binary):	<<Patient Demographics:Gender>>	
Residential Address:	<<Patient Demographics:Address Line 1>>, <<Patient Demographics:Address Line 2>>	
Suburb:	<<Patient Demographics:City>>	State:	<<Patient Demographics:State>>	Postcode:	<<Patient Demographics:Postcode>>	
Is the patient under palliative care with a life expectancy of less than 12 months?		Yes		No	
Please provide any additional information below:	

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

Prescriber Details	
Full Name:	<<Doctor:Name>>	
AHPRA Number:		Prescriber Number:	<<Doctor:Prescriber Number>>	
Practice Address:	<<Doctor:Address Line 1>>, <<Doctor:Address Line 2>>, <<Doctor:City>>, <<Doctor:State>>, <<Doctor:Postcode>>	
Telephone:	<<Doctor:Phone>>	

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

		

Treatment Details	
Specific clinical diagnosis:	
	
Name of specialist (attach relevant specialist report(s) if available):	
	
All other medications (including doses) concurrently prescribed (please attach list):	
<<Clinical Details:Medication List>>	

Declarations (x all that apply or leave blank if not applicable) 	

The patient in my opinion:	

Is drug dependent	

Grounds for drug dependency:	

Iatrogenic	

	

	
	
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:	<<Miscellaneous:Date (short)>>