Buprenorphine Rx Submission

Upload Prescription Form..

Use this form to upload the prescription for the patient
Patient Name*
Medication*
Administration Permitted between*
Prescribers Name:*

PrefixFirst NameLast Name
Facility*

Melaleuca Clinic - Chermside - 07 31394080Caboolture AODS - Phone 07 5316 2476Redcliffe AODSBiala AODS - Phone 07 3837 5666Other
Prescribers Phone Number*

Area CodePhone Number
Prescribers Fax Number

Area CodePhone Number
Prescribers E-Mail Address:
Patient Status*

New to TreatmentExisting Treatment - New to PharmacyExisting Treatment - Already enrolled at Pharmacy
Patient Phone Number

Area CodePhone Number
Medicare Card*
please include the subnumerate
Concession Card
only required if new to pharmacy
Client Address*

Street Address

Street Address Line 2

CityState

Zip CodeCountry
Without a concession card, supply of the medication will cost the patient $30.00 while with a concession card, the medication only costs $7.30

Please enter the patient concession card if there is one
Concession Card status*

The person DOES NOT have a concession card and is aware that they will be charged $30.00 for their medication supplyI don't know if the patient has a concession card. Please check with the patient on administration
Is the patient Date of Birth written on the prescription?*

YesNo
Date of Birth

MonthDayYear
Date
Allergies
Where would the patient like to have their medication administered*

At Woody Point Pharmacy (currently only location available)Caboolture (when available but Woody Point Pharmacy for now)Bribie Island (when available but Woody Point Pharmacy for now)
Thankyou for your input.. This helps us plan for the demand in various areas and helps us prioritise what the needs are in this area so we can accomodate these needs as enough people prefer these certain regions
Is there a change in case Manager?

NoYes
Case Manager

First NameLast Name
Please explain to the patient

1. The location of the pharmacy.. 46 Oxley Ave, Woody Point QLD

2. That they will need to book their administration via our booking engine on woodypointpharmacy.com.au/services/opioid-dependence-service/

3. That they need to adhere to the terms and conditions that are on our website https://www.woodypointpharmacy.com.au/services/opioid-dependence-service/terms-and-conditions

4. That payment is required PRIOR to administration
The patients phone number is handy to have if they have made an error in their selection of the date or there is a temporary supply / staffing issue in which we may need to contact them
Changes to Treatment*

Existing / Current Treatment - No change to previous treatmentPrevious Long Acting Administered - Changing on THIS administration to a different medication
Has the patient been informed about the cost?*

Yes - The patient expects to pay $7.30 (Concession Card)Yes - The Patient expects to pay $30.00No
Please inform the patient that Payment is required prior to administration of their long acting Buprenorphine.
Has the patient been shown how to make an appointment on the pharmacy website*

Yes - The patient has made an appointmentYes - The patient will make an appointment shortlyNo
Please show the patient how easy it is to make an appointment.

Go to www.woodypointpharmacy.com.au and select the SERVICES tab and then select Opioid Dependence Service and select from the variety of appointment times.

Please remind the patient to include their

1. Medicare Card Number and Concession Card (if they have one)

2. Phone number (so we can contact them)

Please also remind the patient that we need THREE business days between when the prescription is uploaded and an appointment can be made.
Has the patient signed the ODT Information and Consent Form?*

Yes. It is attached with the prescriptionNo. The patient is not with me to sign the form
The Patient ODT Information and Consent form is a required form that enables the medication to be supplied under the PBS... To get a copy, click here
Please note that a minimum of THREE BUSINESS DAYS is currently required to ensure we have the stock ordered and staff available prior to the patients administration appointment
Upload Photo of patient here

Upload Photo of Patient
Select multiple files up to 300 MByte, but consider the time needed for uploading! Cancelof
Upload Signed Patient Consent Form Here

Upload the Signed Patient Consent Form Here
Quick link for the consent form https://tinyurl.com/ODTConsent Cancelof
Upload Prescription here*

Upload Prescription Here
Select multiple files up to 300 MByte, but consider the time needed for uploading! Cancelof
Form uploaded by *
Please type your name so we know who to contact if there is more info required
Your Preferred Contact Details*
How should we contact you if there is more information required.
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Upload Prescription Form..