Poison Permit Application Medical Dental Practice

Poisons permit application
Medical/dental practice
Including private hospital and day surgery
Poisons Regulation 10AA
Poisons Act 1964
For enquiries or assistance with completing this form, please contact the Pharmaceutical Services
Branch on 9222 6883 or email [email protected]
Applicants please note:
1.
This application form does not cover mobile immunisation services, aged care facilities or
government hospitals.
2.
Applicants must be registered through the Australian Health Practitioner Registration
Agency (AHPRA) as a Medical practitioner, Dental practitioner, Nurse, Midwife,
Optometrist or Podiatrist.
3.
Penalties apply for providing false or misleading information in this application under
Section 35 of the Poisons Act 1964.
4.
It is the responsibility of the Permit holder to ensure compliance with the Act and Poisons
Regulations 1965, and compliance with conditions placed on the Permit.
5.
Safe for schedule 8 medicines must comply with Pharmaceutical Services Guidance Note
on Purchasing a Safe to Store Schedule 8 Medicines (PDF 84KB)
1. Application type
Doctor’s surgery (general practice or specialist practice)
Day surgery - including dialysis centre
Private hospital
Dental surgery
Nurse practitioner practice
Midwifery practice
Podiatry practice
Optometry practice
2. Applicant
Company name (inc. trading name):
Title:
Surname:
Forename/s:
Health professional type:
Medical practitioner
Midwife
Dentist
Optometrist
Registered nurse
Podiatrist
Nurse practitioner
AHPRA registration number:
Postal address:
Postal suburb:
Postcode:
Telephone:
Fax:
Email:
Poisons permit application Medical/dental
practice
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3. Premises and poisons details
Premises address as above:
Yes
No
Multiple premises
Yes
For multiple premises, please complete the Poisons, Security and Storage sections for each
premises to be named on Permit.
Premises
Premises/practice name:
Premises address:
Premises suburb:
Postcode:
Telephone:
Fax:
Private Hospitals/Day Surgery Centres/Dental Hospitals:
Is the facility licensed under the Hospital and Health Services Act 1927?
Yes
Poisons required
Please tick all that apply:
Schedule 2 – Pharmacy medicine
Schedule 3 – Pharmacist only medicine
Schedule 4 – Prescription only medicine
Schedule 8 – Controlled drug
Please list the Schedule 8 medicines you wish to keep:
Name and strength of medicine:
Approximate quantity kept on hand:
Total quantity of schedule 8 medicines kept on hand - in grams:
Building security
Please tick all that apply:
Dedicated monitored alarm system
Video surveillance system
Motion detectors
Private hospitals/Day surgery centres:
Will poisons be stored in multiple areas in the premises?
If yes, is the security in each area the same?
Poisons storage
Storage area descriptor (floor number, room number etc) –
premises with multiple storage areas only:
Please tick all that apply:
Schedules 2,3 and 4:
Locked room
Locked cupboard
Schedules 2,3,4 – Refrigerated:
Locked room with refrigerator
Locked refrigerator
Yes
Yes
No
No
No
No
Poisons permit application Medical/dental
practice
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Schedule 8 Safe
Complies with Guidance Note on Purchasing a Safe to Store Schedule 8
Yes
No
Medicines (PDF 84KB)?
Safe make and model number:
If make/model unknown, please provide two photos of the safe – one with the door closed and
one with the door open, with a ruler held against the door to show the thickness of the door plate.
What is the safe bolted to?
Please provide photos to show how the safe has been bolted in place.
4. Access
Please tick to confirm that only registered health practitioners will have access to scheduled
medicines including access to the safe key/s and combination code.
Please confirm that Schedule 4 and 8 medicines will only be administered in accordance with
an order for each individual patient by a medical practitioner, nurse practitioner, dentist or
other health practitioner endorsed to prescribe.
5. Recording
Please indicate how records of administration and supply of medicines are maintained:
Schedules 2,3 and 4
Patient notes:
Yes
No
Schedule 8
Patient notes:
Yes
No
Schedule 8 register - HA14: Yes
No
How often is Schedule 8 stock balance checked?
6. Declaration
I,
provide full name
of:
provide full address
hereby declare:
i.
I am over 21 years of age.
ii.
The information contained in this application form to be true and correct.
iii.
I am aware that penalties apply under section 35 of the Poisons Act 1964 for providing
false or misleading information in this application.
iv.
I am familiar with the provisions of the Poisons Act 1964 and Poisons Regulations 1965
relevant to the poisons to which this application relates.
v.
As permit holder I am aware of my responsibility for the safe storage and use of poisons
and will ensure compliance with the Poisons Act 1964 and Poisons Regulations 1965,
and compliance with conditions placed on the permit.
vi.
I will notify the Department of Health if details on this form change including:
if the permit holder leaves employment or takes extended leave
if there is a change of premises or storage address
when additional poisons are required
Signature of applicant:
Date:
Poisons permit application Medical/dental
practice
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Payment options
Application fee:
1 year: $240, 3 years: $360
Cheque or money order – made payable to: DEPARTMENT OF HEALTH
Credit card (American Express and Diners not accepted)
Card type:
Mastercard
Visa
Name on card:
Amount :
$240
Card number:
Expiry date:
Signature of cardholder:
Date:
Direct debit to bank
Bank: Commonwealth Bank
BSB: 066 040
Amount:
$240
$360
Receipt Number:
Account number: 13300018
Payment date:
Submission
Please post completed form to:
Health Corporate Network
PO Box 8549
PERTH BUSINESS CENTRE WA 6849
Payment enquiries: 1300 367 132
$360