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Getting Started

Notification of drug dependent person
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Who should complete this form?
A medical practitioner or nurse practitioner who has reason to believe that a patient is a drug dependent person is required to notify the department where:
- the patient requests or seeks prescription of a Schedule 8 or Schedule 9 drug, or a Schedule 4 drug which is also a drug of dependence, or
- the practitioner intends to treat or is treating the patient with a Schedule 8 or Schedule 9 drug, or a Schedule 4 drug which is also a drug of dependence.
Notifications will be processed by Drugs and Poisons Regulation who can be contacted on 1300 364 545 or via email dpcs@dhhs.vic.gov.au.

NOTE: Once you have completed and submitted this notification, you will receive a confirmation email that your notification has been received by the department, as well as a PDF of the notification for your records.

Prescriber Details

Notification of drug dependent person
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Your details

Patient details

Notification of drug dependent person
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Patient Details

Notification details

Notification of drug dependent person
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Notification Details

I have reason/s to believe that is drug dependent and my belief is based on the following grounds *
Is currently a hospital in-patient or prisoner being treated with methadone and/or buprenorphine for opioid dependence? *
Did request a Schedule 8 or Schedule 9 drug, or a Schedule 4 drug of dependence?
Do you intend to prescribe any Schedule 8 or Schedule 9 drug, or Schedule 4 drug of dependence for ?
If you are intending to prescribe a Schedule 8 or Schedule 9 drug, you need to obtain a permit to do so before prescribing. Please refer to the explanatory notes for further information.
If you have any additional documentation, please click below to attach
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Declaration

Notification of drug dependent person
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Declaration

I, , declare the information provided in this notification is true and complete to the best of my knowledge.

Privacy Statement

It is a requirement of the Drugs, Poisons and Controlled Substances Act 1981 (the Act) that the information set out in this form is provided to the Department of Health & Human Services to meet statutory notification requirements, and for the issuing of permits as required under the Act. The collection, use and disclosure of the information provided will be in accordance with the law, including the provisions of the Health Records Act 2001. The information collected may be disclosed to health practitioners practising in the following health professions: medical, nursing and midwifery and pharmacy, when necessary to facilitate coordination of the patient's drug treatment and safe prescribing of drugs. For example, it may be necessary to disclose this information when another health practitioner applies for a permit or is considering prescribing a drug of dependence. The notification may not be processed if all information requested on the form is not completed.

Remember Me

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Department of Health & Human Services