Sch. Sch. 2 2 DP2 Sch. 2 Form DP2 Regulation 19(1) substituted by S.R. No. Drugs, Poisons and Controlled Substances Regulations 2006 16/2009 reg. 8(1), TREATMENT 9 amended by S.R. No. 131/2010 (Application for permit to administer, prescribe or supply) reg. 25(2). FOR 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 __________________
Sch. 2 Form DP2 substituted by S.R. No. 16/2009 reg. 8(1), amended by S.R. No. 131/2010 reg. 25(2). DP2 Sch. 2 Regulation 19(1) Drugs, Poisons and Controlled Substances Regulations 2006 9 (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 __________________ Sch. 2
06-57sr014.docx