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Application for a warrant to obtain, use, supply or prescribe restricted Schedule 4 medicines

Fields marked with * are required

This form is for prescribers who need to apply for a warrant to treat patients with one or more of the following restricted Schedule 4 medicines:•Ovulatory stimulants•Prostaglandins•Retinoids•Immunomodulatory drugs (IMiDs) (thalidomide or its analogues)

Prescriber Details

Fields marked with * are required

Your details

Title *

First Name *

Last Name *

Ahpra Registration Number *

Qualifications (select all applicable) *

MBBS

MBChB

MD

FRACP

FRANZCOG

FACD

Other

Other qualification(s):

Practice details

Practice Name

Street Address *

Suburb *

State *

Postcode *

Email *

Business Phone *

Fax Number

Supporting documentation

Application for a warrant to obtain, use, supply or prescribe restricted Schedule 4 medicines

Fields marked with * are required

In support of your application, please attach the following:

Evidence of specialist qualifications

Attach documentary evidence of your relevant specialist qualifications here:

File:

Supporting documentation

Attach documentary evidence of your accreditation to practice obstetrics at a hospital here:

File:

Supporting documentation

Attach documentary evidence of your appointment as an obstetrics and gynaecology registrar in a training program in a public hospital or evidence that you are a Member of the College (MRANZCOG) here:

File:

Additional comments

Patient-based warrant (ovulatory stimulant)

Application for a warrant to obtain, use, supply or prescribe restricted Schedule 4 medicines

Fields marked with * are required

Patient-based warrant details

If "clomiphene citrate for other purposes" has been selected, the following details must be completed:

Patient Details

Given Name *

Family Name *

Address *

Suburb *

State *

Postcode *

Date of Birth (dd/mm/yyyy) *

Sex *

Clinical Diagnosis *

Evidence of specialist qualifications

1. Attach documented evidence confirming your specialist qualifications and that you are a specialist in a field relevant to the patient's medical condition:

File:

Evidence demonstrating efficacy for the therapeutic use of clomiphene citrate for the patient’s condition

2. Attach documented evidence or medical literature which demonstrates efficacy for the therapeutic use of clomiphene citrate for the patient's medical condition:

File:

Additional comments

Patient-based warrant (retinoid)

Application for a warrant to obtain, use, supply or prescribe restricted Schedule 4 medicines

Fields marked with * are required

Patient-based warrant details

If "a retinoid for other purposes" has been selected, the following details must be completed:

Patient Details

Given Name *

Family Name *

Address *

Suburb *

State *

Postcode *

Date of Birth (dd/mm/yyyy) *

Sex *

Clinical Diagnosis *

Retinoid: (select relevant drug) *

acitretin

etretinate

isotretinoin

tretinoin

Evidence of specialist qualifications

1. Attach documented evidence confirming your specialist qualifications and that you are a specialist in a field relevant to the patient's medical condition:

File:

Evidence demonstrating efficacy for the therapeutic use of the retinoid for the patient’s condition

2. Attach documented evidence or medical literature which demonstrates efficacy for the therapeutic use of the retinoid for the patient's medical condition:

File:

Additional comments

Patient-based warrant (IMiDs)

Application for a warrant to obtain, use, supply or prescribe restricted Schedule 4 medicines

Fields marked with * are required

Patient-based warrant details

If "thalidomide, lenalidomide or pomalidomide for other purposes" has been selected, the following details must be completed:

Patient Details

Given Name *

Family Name *

Address *

Suburb *

State *

Postcode *

Date of Birth (dd/mm/yyyy) *

Sex *

Clinical Diagnosis *

Immunomodulatory drug (IMiD): (select relevant drug) *

thalidomide

lenalidomide

pomalidomide

Evidence of specialist qualifications

1. Attach documented evidence confirming your specialist qualifications and that you are a specialist in a field relevant to the patient's medical condition:

File:

Evidence demonstrating efficacy for the therapeutic use of the IMiD for the patient’s condition

2. Attach documented evidence or medical literature which demonstrates efficacy for the therapeutic use of the IMiD for the patient's medical condition:

File:

Support from a relevant ethics committee

3. Attach documented evidence of support for your application from a relevant ethics committee, such as from a hospital or a professional College in your field of specialty:

File:

Additional comments

Declaration

Application for a warrant to obtain, use, supply or prescribe restricted Schedule 4 medicines

Fields marked with * are required

Declaration

This application forms part of a legal document and penalties exist for providing false or misleading information.

I, , declare that:

I will treat only the following patients with a retinoid:
a. males; or
b. females who are not pregnant or for whom the possibility of pregnancy occurring can be ruled out or that adequate safeguards are in place to ensure that pregnancy does not occur during the course of treatment; and
i. for one month after cessation of treatment with isotretinoin or tretinoin; and
ii. for two years after cessation of treatment with acitretin or etretinate.

I will undertake to use prostaglandins for obstetric purposes only under conditions where facilities for cardiotocographic monitoring and emergency Caesarean section are available.

For patients treated with immunomodulatory drugs (IMiDs), I will take all reasonable steps to ensure that:
a. for females pregnancy can be ruled out, or that adequate safeguards are in place to ensure that pregnancy can be ruled out during treatment with the drug and for at least one month after stopping the drug;
b. sexually active males who have not had a vasectomy are informed that it is recommended that:
i. they abstain from sexual intercourse, or use a condom during intercourse, while receiving the drug, and continuing thereafter until one month after the last dose, and
ii. sperm should not be donated during this period.

I confirm the information I provided in this application is true and complete to the best of my knowledge.

By ticking this checkbox, I confirm I have read and understood the above statement. *

Privacy Collection Notice

By completing this form, you acknowledge that you are providing the personal and health information as required under the Drugs, Poisons and Controlled Substances Act 1981 (the Act) to the Department of Health, Victoria (the Department) for the purpose of applying to the Department in relation to a warrant for restricted Schedule 4 medicines.

The information is handled by the Department in accordance with the requirements of the Act, Drugs, Poisons and Controlled Substances Regulations 2017 (Vic), Privacy and Data Protection Act 2014 (Vic), Health Records Act 2001 (Vic) and the Department’s privacy policy.

The information collected by the Department:

•will be used and disclosed for the purposes of assessing the warrant application;•will be used and disclosed for monitoring and compliance purposes;•may be disclosed to other relevant health practitioners when necessary to facilitate coordination of the patient's drug treatment and safe prescribing of drugs (if applicable); and•may be disclosed for any other purposes permitted by law including but not limited to reporting or investigation of suspected unlawful activity to regulatory and law enforcement agencies in the Commonwealth, States and Territories; and Ahpra.
By submitting this form, health practitioners confirm that the patient (if applicable): •is aware of the contents of this collection notice; and•has consented to the form being submitted.
If you do not provide all the required information, the application may not be processed.

You can download a PDF copy of the completed form or request a confirmation email at the Submission Complete page.

For further information about Victorian Drugs and Poisons legislation, please visit the Medicines and Poisons Regulation website at www.health.vic.gov.au/dpcs.

For further information on privacy and how to access and seek correction of personal information about you held by the Department, visit www.health.vic.gov.au/privacy.

Need Assistance?

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Application for a warrant to obtain, use, supply or prescribe restricted Schedule 4 medicines

Prescriber Details

Your details

Practice details

Warrant details

Ovulatory stimulant details

Prostaglandin details

Retinoid details

IMiDs details

Supporting documentation

In support of your application, please attach the following:

Evidence of specialist qualifications

Supporting documentation

Supporting documentation

Patient-based warrant (ovulatory stimulant)

Patient-based warrant details

Evidence of specialist qualifications

Evidence demonstrating efficacy for the therapeutic use of clomiphene citrate for the patient’s condition

Patient-based warrant (retinoid)

Patient-based warrant details

Evidence of specialist qualifications

Evidence demonstrating efficacy for the therapeutic use of the retinoid for the patient’s condition

Patient-based warrant (IMiDs)

Patient-based warrant details

Evidence of specialist qualifications

Evidence demonstrating efficacy for the therapeutic use of the IMiD for the patient’s condition

Support from a relevant ethics committee

Declaration

Declaration

Privacy Collection Notice