Request for adrenaline autoinjector to be provided on PBS Authority prescription by Clinical Immunologist / Allergist
Please refer to the ASCIA adrenaline autoinjector prescription guidelines on the ASCIA website:
 http://www.allergy.org.au/health-professionals/hp-information/asthma-and-allergy/anaphylaxis/11-ascia-guidelines-for-adrenaline-autoinjector-prescription

Prescribing doctor details
Doctor’s name		
Email address		
Provider number		
Phone		
Address		
Fax		
Date		
Signature		
 
Patient Details
Patient name		
Date of Birth		
		
Date of last reaction		
Suspected allergen		
Confirmed by skin testing?	Yes  / No	
Confirmed by sIgE/RAST?	Yes /  No	
		
Did the patient have an anaphylactic reaction?	Yes  /  No	
Or a severe generalised allergic reaction?	Yes  /  No	
		
Modifying factors		
Asthma	Yes  /  No	
Adolescent or young adult	Yes  /  No	
Nut allergy (peanut or tree nut)	Yes  /  No	
Sting insect allergy (bee, wasp, ant)	Yes  /  No	
Co-morbid disease (e.g. IHD, COPD)	Yes  /  No	
Limited access to emergency care	Yes  /  No	

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 the clinical immunologist / allergist?	Yes / No	
(If so, please provide a referral letter and contact details for the patient so an appointment may be arranged)

For completion by the clinical immunologist / allergist
The information provided complies with adrenaline autoinjector prescription guidelines.	Yes  /  No	
Assessment by immunologist / allergist recommended.	Yes  /  No	
Dr. David Heyworth-Smith signature:	                                                  Date:	

NB. Decisions about patient advice on adrenaline autoinjectors and instructions for use remain the responsibility of the prescribing doctor.
Request for adrenaline autoinjector to be provided on PBS Authority prescription by Clinical Immunologist / Allergist
Please refer to the ASCIA adrenaline autoinjector prescription guidelines on the ASCIA website:
 http://www.allergy.org.au/health-professionals/hp-information/asthma-and-allergy/anaphylaxis/11-ascia-guidelines-for-adrenaline-autoinjector-prescription

Prescribing doctor details
Doctor’s name	<<Doctor:Name>>	
Email address	<<Doctor:E-mail>>	
Provider number	<<Doctor:Provider Number>>	
Phone	<<Doctor:Phone>>	
Address	<<Doctor:Full Address>>	
Fax	<<Doctor:Fax>>	
Date	<<Miscellaneous:Date>>	
Signature		
 
Patient Details
Patient name	<<Patient Demographics:Full Name>>	
Date of Birth	<<Patient Demographics:DOB>>	
		
Date of last reaction		
Suspected allergen		
Confirmed by skin testing?	Yes  / No	
Confirmed by sIgE/RAST?	Yes /  No	
		
Did the patient have an anaphylactic reaction?	Yes  /  No	
Or a severe generalised allergic reaction?	Yes  /  No	
		
Modifying factors		
Asthma	Yes  /  No	
Adolescent or young adult	Yes  /  No	
Nut allergy (peanut or tree nut)	Yes  /  No	
Sting insect allergy (bee, wasp, ant)	Yes  /  No	
Co-morbid disease (e.g. IHD, COPD)	Yes  /  No	
Limited access to emergency care	Yes  /  No	

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 the clinical immunologist / allergist?	Yes / No	
(If so, please provide a referral letter and contact details for the patient so an appointment may be arranged)

For completion by the clinical immunologist / allergist
The information provided complies with adrenaline autoinjector prescription guidelines.	Yes  /  No	
Assessment by immunologist / allergist recommended.	Yes  /  No	
Dr. David Heyworth-Smith signature:	                                                  Date:	

NB. Decisions about patient advice on adrenaline autoinjectors and instructions for use remain the responsibility of the prescribing doctor.

Request for adrenaline autoinjector to be provided on PBS Authority prescription by Clinical Immunologist / Allergist
Please refer to the ASCIA adrenaline autoinjector prescription guidelines on the ASCIA website:
 http://www.allergy.org.au/health-professionals/hp-information/asthma-and-allergy/anaphylaxis/11-ascia-guidelines-for-adrenaline-autoinjector-prescription

Prescribing doctor details
Doctor’s name	<<Doctor:Name>>	
Email address	<<Doctor:E-mail>>	
Provider number	<<Doctor:Provider Number>>	
Phone	<<Doctor:Phone>>	
Address	<<Doctor:Full Address>>	
Fax	<<Doctor:Fax>>	
Date	<<Miscellaneous:Date>>	
Signature		
 
Patient Details
Patient name	<<Patient Demographics:Full Name>>	
Date of Birth	<<Patient Demographics:DOB>>	
		
Date of last reaction		
Suspected allergen		
Confirmed by skin testing?	Yes  / No	
Confirmed by sIgE/RAST?	Yes /  No	
		
Did the patient have an anaphylactic reaction?	Yes  /  No	
Or a severe generalised allergic reaction?	Yes  /  No	
		
Modifying factors		
Asthma	Yes  /  No	
Adolescent or young adult	Yes  /  No	
Nut allergy (peanut or tree nut)	Yes  /  No	
Sting insect allergy (bee, wasp, ant)	Yes  /  No	
Co-morbid disease (e.g. IHD, COPD)	Yes  /  No	
Limited access to emergency care	Yes  /  No	

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 the clinical immunologist / allergist?	Yes / No	
(If so, please provide a referral letter and contact details for the patient so an appointment may be arranged)

For completion by the clinical immunologist / allergist
The information provided complies with adrenaline autoinjector prescription guidelines.	Yes  /  No	
Assessment by immunologist / allergist recommended.	Yes  /  No	
Dr. David Heyworth-Smith signature:	
Date:	

NB. Decisions about patient advice on adrenaline autoinjectors and instructions for use remain the responsibility of the prescribing doctor.