Adrenaline Autoinjector Approval Request

Request for adrenaline autoinjector

Clinical agreement by Immunologist/Allergist
Request for clinical agreement by Clinical Immunologist / Allergist for PBS Authority prescription of an adrenaline autoinjector

Please refer to the ASCIA adrenaline autoinjector prescription guidelines on the ASCIA website: https://www.allergy.org.au/hp/anaphylaxis/adrenaline-autoinjector-prescription
Prescribing Doctor's Name *

First Name Last Name
Phone *
Email *
example@example.com
Address *

Street Address

Street Address Line 2

City State

Postal Code
Fax
Date *

Day Month Year
Patient Details
Name *

First Name Last Name
Birth Date *

Day Month Year
Date of last reaction

Day Month Year
Suspected allergen
Confirmed by testing?
Did the patient have an anaphylactic reaction?
Modifying Factors

Asthma Adolescent or young adult Nut allergy (peanut or tree nut) Stinging insect allergy (bee, wasp, ant) Co-morbid disease (e.g. IHD, COPD) Limited access to emergency care
Has the patient been given an Action Plan for Anaphylaxis? (This is a PBS requirement) *

Yes No
Would you like this patient to be seen by a clinical immunologist/allergist at Compass Immunology? *

Yes (Please provide a referral letter so an appointment may be arranged) No
How would you like this completed form returned? *

Medical Objects Email Fax Post
Further comments (optional)
NB. Decisions about patient advice on adrenaline autoinjectors and instructions for use remain the responsibility of the prescribing doctor.

Please scroll to bottom and submit.

The Immunologist/Allergist at Compass Immunology Clinic will complete the next section.
For completion by the clinical immunologist / allergist
The information provided complies with adrenaline autoinjector prescription guidelines.

Yes No
Reasons for decision (optional)
Specialist Immunologist assessing
Date:
Signature

Clear
Should be Empty:

Request for adrenaline autoinjector

Patient Details