Amino Acid Formula Approval Request

Request for clinical agreement to prescribe amino acid formula
Request for clinical agreement from Clinical Immunologist / Allergist to prescribe amino acid formula on PBS Authority prescription

Please refer to the PBS prescribing criteria to ensure your patient is eligible.

Please complete and submit and we will return the form as reviewed by a Specialist for your patient record.
Prescribing Doctor's Name *

First Name Last Name
Medical Practice Specialty *
Email *
example@example.com
Phone number *
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
Parent or Guardian name *

First Name Last Name
Reason(s) for request (please select any that apply). *

Anaphylaxis to cow's milk protein Intolerance to soy Intolerance to protein hydrolysate formula (Alfaré, Karicare Aptamil Pepti-Junior Gold) Cows' milk protein enteropathy that is not isolated colic or reflux
Has the child been seen by a: *

Paediatrician Gastroenterologist Immunologist/Allergist
If so, please provide the name of specialist
What other options has the child received? (Please select any that apply) *

Standard cow's milk based formula Soy formula Protein hydrolysate formula e.g. Aptamil Allerpro, Pepti-junior Rice based formula eg. Novalac Allergy Breast milk
Has the patient an appointment to see an Immunologist/Allergist? *

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
Formula requested

Neocate Syneo Neocate Gold Neocate LCP Neocate Junior Neocate Junior Vanilla Elecare Elecare LCP Elecare Vanilla Alfamino Alfamino Junior
Further comments (optional)
Please scroll to the end to submit.

Leave the following section blank for use by Compass Immunology.
Compass Immunology Specialist
Clinical agreement to prescribe amino acid formula

Approved Not approved
Date
Should be Empty:

Request for clinical agreement to prescribe amino acid formula

Patient Details

Please scroll to the end to submit.