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Notification of drug dependent person
Contact Drugs and Poisons Regulation
If you are experiencing difficulties in completing or submitting this notification, please contact Drugs and Poisons Regulation on 1300 364 545 Monday - Friday 10am-4pm or email us at dpcs@dhhs.vic.gov.au.
See
explanatory notes
for information on permit and notification requirements. You can also visit our
website
for further information.
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Getting Started
Notification of drug dependent person
Fields marked with
*
are required
Who should complete this form?
This form is for medical practitioners or nurse practitioners intending to treat a person who they have reason to believe is a drug-dependent person.
Prescriber Details
Notification of drug dependent person
Fields marked with
*
are required
Your details
Title
*
Dr
Prof
Mr
Ms
Mrs
Miss
Given Name
*
Family Name
*
Qualifications
*
MBBS/MBChB
FRACGP
FRACP
FRANZCP
FAChAM
FAChPM
FFPMANZCA
RN, NP
MD
AHPRA Registration Number
*
Practice Name
Street Address
*
Suburb
*
State
ACT
NSW
NT
QLD
SA
TAS
VIC
WA
Postcode
*
Email
*
Business Phone
*
Fax Number
Patient details
Notification of drug dependent person
Fields marked with
*
are required
Patient Details
Title
Mr
Mrs
Miss
Ms
Given Name
*
Surname
*
Property Name
Street Address
*
Suburb
*
State
*
ACT
NSW
NT
QLD
SA
TAS
VIC
WA
Postcode
*
Date of Birth (dd/mm/yyyy)
*
Sex
*
Male
Female
Intersex/Indeterminate/Unspecified
Aliases
Notification details
Notification of drug dependent person
Fields marked with
*
are required
Notification Details
I have reason/s to believe that
is drug dependent and my belief is based on the following grounds
*
Admits current misuse/abuse of pharmaceutical drugs
Admits current misuse or abuse of illicit drugs
Is "doctor shopping" for prescription drugs
Has physical signs of intravenous drug use
Has obtained prescription drugs from illicit sources
Has been forging prescriptions
Has had multiple unsanctioned dose escalations of prescribed drugs
Another prescriber holds a permit for opioid replacement therapy (ORT) (methadone syrup or buprenorphine tablet/film)
Other
Is
currently a hospital in-patient or prisoner being treated with methadone and/or buprenorphine for opioid dependence?
*
Yes
No
Did
request a Schedule 8 or Schedule 9 drug, or a Schedule 4 drug of dependence?
Yes
Please specify which drugs were requested
*
No
Do you intend to prescribe any Schedule 8 or Schedule 9 drug, or Schedule 4 drug of dependence for
?
Yes
If you are intending to prescribe a Schedule 8 drug, you need to obtain a permit to do so before prescribing. To apply for a permit, please visit
Online Forms - Medicines and Poisons Regulation
.
Please specify which drugs you intend to prescribe
*
No
If you have any additional documentation, please click below to attach
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Additional comments
Declaration
Notification of drug dependent person
Fields marked with
*
are required
Declaration
I,
, declare the information provided in this notification is true and complete to the best of my knowledge.
By ticking this checkbox, I confirm that I have read and understood the above statement.
*
Date
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 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.
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