DP1 Sch. 2 Form DP1 Regulation 18 substituted by S.R. No. Drugs, Poisons and Controlled Substances Regulations 2006 16/2009 reg. 8(1), PERSON amended by S.R. No. I, [full of name of registered medical practitioner/nurse practitioner] 131/2010 reg. 24(1). [address, telephone and fax numbers of registered medical practitioner/nurse practitioner] have reason to believe that [full of [address is name of patient] of patient] dependent on [name and my belief is based on the following of drug(s)] grounds: PATIENT DETAILS Aliases (if any) Sex Date of birth Approximate period of drug dependency Other drugs used by patient DPU number (if known) Source of drugs Is it your intention to prescribe Was a a Schedule 8 poison or If so, which Schedule poison(s) 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 __________________
Sch. 2 Form DP1 substituted by S.R. No. 16/2009 reg. 8(1), amended by S.R. No. 131/2010 reg. 24(1). DP1 Regulation 18 Drugs, Poisons and Controlled Substances Regulations 2006 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) Sex Date of birth Approximate period of drug dependency Other drugs used by patient DPU number (if known) Source of drugs Was a 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 __________________ PERSON