Victorian Consolidated Regulations

Drugs, Poisons and Controlled Substances Regulations 2006 - SCHEDULE 2

FORMS FORM DP1 Regulation 18 Drugs, Poisons and Controlled Substances
Regulations 2006 NOTIFICATION OF DRUG-DEPENDENT PERSON I, [full name of
registered medical practitioner/nurse practitioner] of [address, telephone and
fax numbers of registered medical practitioner/nurse practitioner]

have reason to believe that [full name of patient] of [address of patient] is
dependent on [name of drug(s)] and my belief is based on the following
grounds: PATIENT DETAILS Aliases (if any) Height Occupation Sex Date of birth

Approximate period of drug dependency Other drugs used by patient DPU number
(if known) Source of drugs Was a Schedule 8 poison or poison or a Schedule 4
poison that is a drug of dependence requested? If so, which Schedule poison(s)
Is it your intention to prescribe a Schedule 8 poison or Schedule 9 poison or
a Schedule 4 poison that is a drug of dependence? If so, which Schedule
poison(s)

Signature of registered medical practitioner/nurse practitioner Date

__________________

FORM DP2 Regulations 19(1) Drugs, Poisons and Controlled Substances
Regulations 2006 TREATMENT WITH SCHEDULE 9 POISONS BY A REGISTERED MEDICAL
PRACTITIONER (Application for permit to administer, prescribe or supply) FOR
TREATMENT WITH SCHEDULE 9 POISONS Section 1: (To be completed in all cases)
Full name of patient Date of birth Sex Private address of patient Postcode

Full name and qualifications of registered medical practitioner Address of
registered medical practitioner Postcode

Telephone and fax no. of registered medical practitioner Name and address of
hospital where patient is undergoing treatment (if applicable) Clinical
diagnosis Attach research literature which supports the efficacy of the
Schedule 9 poison for that clinical diagnosis Pharmaceutical product which
contains the Schedule 9 poison Country in which the Schedule 9 poison is
registered for therapeutic use

Section 2: Schedule 9 poison(s) for which permit is requested: NAME OF
POISON(S) EXPECTED MAXIMUM DAILY DOSE









Details of other treatment (if applicable)

Signature of registered medical practitioner Date

__________________

FORM DP2A Regulations 19(2), 22A Drugs, Poisons and Controlled Substances
Regulations 2006 TREATMENT WITH SCHEDULE 8 POISONS BY A REGISTERED MEDICAL
PRACTITIONER OR A NURSE PRACTITIONER (Application for permit to administer,
prescribe or supply) PART A: FOR TREATMENT WITH SCHEDULE 8 POISONS OTHER THAN
TREATMENT OF AN OPIOID DEPENDENT PERSON WITH METHADONE OR BUPRENORPHINE
Section 1: (To be completed in all cases) Full name of patient Date of birth
Sex Private address of patient Postcode

Full name and qualifications of registered medical practitioner/nurse
practitioner Address of registered medical practitioner/nurse practitioner
Postcode

Telephone and fax no. of registered medical practitioner/nurse practitioner
Name and address of hospital where patient is undergoing treatment (if
applicable) Clinical diagnosis

Section 2: Schedule 8 poison(s) for which permit is requested: NAME OF
POISON(S) EXPECTED MAXIMUM DAILY DOSE







Details of other treatment (if applicable)



Signature of registered medical practitioner/nurse practitioner Date

PART B: FOR TREATMENT OF AN OPIOID DEPENDENT PERSON WITH METHADONE OR
BUPRENORPHINE I, [full name of registered medical practitioner/nurse
practitioner] of [address of registered medical practitioner/nurse
practitioner, including postcode, phone and fax numbers] certify that this
patient shows evidence of dependence on an opioid drug and that, in my
opinion, methadone/buprenorphine is required in support of treatment. Personal
Details: Full name of patient Address of patient Date of birth DPU client
number (if known) Sex Aliases (if any) Mother's full maiden name Height
Medical Details of Patient: Starting drug Starting methadone/buprenorphine
dose Anticipated date of first dose Period for which permit sought (if short
term)
Has the patient been treated previously with methadone or buprenorphine for opioid dependency?    Yes/No
Is the patient transferring from another prescriber? Yes/No If yes, what was
the last drug prescribed? When was the last dose administered? Has the
previous prescriber been advised of the transfer? Yes/No Name of previous
prescriber Name, address and telephone number of person dispensing
methadone/buprenorphine

Signature of registered medical practitioner/nurse practitioner Date
__________________

FORM DP3 Regulation 20, 22B(3) Drugs, Poisons and Controlled Substances
Regulations 2006 SCHEDULE 8 PERMIT/SCHEDULE 9 PERMIT This permit is granted to
[full name and address of registered medical practitioner/nurse practitioner]
and authorises that registered medical practitioner/nurse practitioner to
administer, prescribe or supply the following poison(s) in accordance with the
following details and conditions. The poison(s) must not be administered,
prescribed or supplied in excess of the quantities specified, or for a period
greater than that specified in this permit. Name of patient Address of patient

NAME OF POISON MAXIMUM DOSE

Special conditions: (if any) This permit is valid from [date] to [date (if
applicable)] unless sooner revoked or suspended. Date Secretary
__________________ FORM DP4 Regulation 72 Drugs, Poisons and Controlled
Substances Regulations 2006 NOTICE OF SEIZURE To of

I,                                    an authorised officer under the Drugs, Poisons and Controlled Substances Act 1981 give notice that I have at            a.m./p.m. this day seized on the following grounds:
at
in the municipal district of                                                          the poisons or controlled substances, other substances or documents described below:
of which you are Unless you, or a person claiming the poisons or controlled
substances, other substances or documents complain to a registrar of the
Magistrates' Court within 96 hours of seizure by giving notice of complaint in
the form of Form DP5 to the Drugs, Poisons and Controlled Substances
Regulations 2006, and a copy of that notice to the authorised officer who made
the seizure, the poisons or controlled substances, other substances or
documents will be destroyed or disposed of. Dated at this day of
20    ,
at a.m./p.m.





Authorised Officer Whose address for service of any notice of complaint
verified by an accompanying statutory declaration is _______________ FORM DP5
Regulation 73 Drugs, Poisons and Controlled Substances Regulations 2006 NOTICE
OF COMPLAINT IN RESPECT OF A SEIZURE Sch. 2 To the registrar of the
Magistrates' Court at I, of

[Full name]

[Address] being claimant of the poisons or controlled substances, other
substances or documents described below- which were seized by on the day of at
a.m./p.m., in accordance with section 43(2) of the
Drugs, Poisons and Controlled Substances Act 1981, complain about that
seizure.

[Signature of complainant] [Date] Note:

Section 43(2) of the Drugs, Poisons and Controlled Substances Act 1981
requires that in lodging a notice of complaint to the registrar of the
Magistrates' Court-

   (a)  the notice must be verified by an accompanying statutory declaration;
        and

   (b)  a copy of the notice and statutory declaration must be given to the
        authorised officer who made the seizure. __________________

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