Victorian Numbered Regulations

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DRUGS, POISONS AND CONTROLLED SUBSTANCES AMENDMENT (MDMA AND PSILOCYBINE) REGULATIONS 2023 (SR NO 61 OF 2023) - REG 15

Schedule 2 amended

In Schedule 2 to the Principal Regulations, after Form 6 insert

" FORM 7

Regulation 17A

Drugs, Poisons and Controlled Substances Regulations 2017

NOTICE OF INTENTION TO PRESCRIBE, AUTHORISE TO ADMINISTER, OR ADMINISTER SCHEDULE 8 MDMA OR SCHEDULE 8 PSILOCYBINE

Section 1: Psychiatrist or medical practitioner's details

First name and surname        

Practice address

Qualifications

Health Practitioner Regulation National Law registration number 

TGA Authorised Prescriber approval number (if applicable)

Phone number

Email address

Section 2: Person's details

First name and surname 

Address

Date of birth 

Sex

Name and address of site where the person is receiving treatment 

Substance details

Name of substance 

Proprietary name (if available)

Dose form and strength

Maximum dose and frequency

Anticipated date(s) of administration

Local Australian supplier details

Name and address of local Australian supplier (e.g. pharmacy or wholesaler)

Details of other treatment (if applicable)

Name of Clinical Trial (if applicable)

Clinical Trial Notification ID/Clinical Trial Approval ID (if applicable)

Ethics approval number (if applicable)

Name of Human Research Ethics Committee that granted the ethics approval (if applicable)".

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