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Poisons permit application
Veterinary practice
including mobile vets
Poisons Regulation 10AA
Poisons Act 1964
For enquiries or assistance with completing this form, please contact the Pharmaceutical Services
Branch on 9222 6883 or email [email protected]
Applicants please note:
1. Applicants must be registered with the Veterinary Surgeons Board of Western Australia.
2. Penalties apply for providing false or misleading information in this application under Section
35 of the Poisons Act 1964.
3. It is the responsibility of the permit holder to ensure compliance with the Act and Poisons
Regulations 1965, and compliance with conditions placed on the permit.
4. Safes must comply with Pharmaceutical Services Guidance Note on Purchasing a Safe to
Store Schedule 8 Medicines PDF 84KB.
1. Applicant
Title:
Surname:
Company name if applicable:
Veterinary Registration Number:
Postal address:
Postal suburb:
Telephone:
Email:
Forename/s:
Postcode:
Fax:
2. Poisons required
Please tick all that apply:
Schedule 2 – Pharmacy medicine
Schedule 3 – Pharmacist only medicine
Schedule 4 – Prescription animal remedy
Schedule 8 – Controlled drug
Note: A permit is not required to purchase and supply veterinary medicines in schedules 5 and 6.
Please list the Schedule 8 medicines you wish to keep:
Name and strength of medicine:
Approximate quantity kept on hand:
Total quantity of Schedule 8 medicines kept on hand - in grams:
Poisons permit application Veterinary
practice
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3. Practice type and premises details
Mobile vet operating only in this manner, please complete section 3.1
Registered premises (may include off-site treatment), please complete section 3.2
3.1 Mobile vet
Please tick to confirm the following statements:
Scheduled medicines are only stored in vehicles when attending patients
At all other times medicines are stored at the secure premises listed below
Mobile vet after hours storage address
Storage address same as postal?
Yes
Storage address:
Storage suburb:
No
Postcode:
3.2 Registered premises
For multiple premises, please complete sections 3.2 and 4 for each premise to be named on the
permit.
Premises/practice – name:
Is the premises registered under the Veterinary Surgeons Act 1960?
Yes
Premises address same as postal?
Yes
No
Premises address
Premises address:
Premises suburb:
Postcode:
Telephone:
Fax:
No
4. Security and storage
4.1 Building security
Please tick all that apply:
Dedicated monitored alarm system
Video surveillance system
Motion detectors
Mud map:
Please provide a mud map or sketch diagram of the premises showing where the medicines
will be stored. Mark on the diagram the location of lockable doors, movement detectors and
video surveillance cameras (if applicable).
4.2 Poisons storage
Storage area – name/description:
Please tick all that apply:
Schedules 2,3 and 4:
Locked room
Locked cupboard
Schedules 2,3,4 – Refrigerated:
Locked room with refrigerator
Locked refrigerator
Poisons permit application Veterinary
practice
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Schedule 8 Safe
Complies with: Guidance Note on Purchasing a Safe to Store Schedule 8
Yes
No
Medicines PDF 84KB?
Safe make and model number:
If make/model unknown, please provide two photos of the safe – one with the door closed and one
with the door open, with a ruler held against the door to show the thickness of the door plate.
What is the safe bolted to?
Please provide photos to show how the safe has been bolted in place.
5. Access
Please tick to confirm the following statements:
Only registered veterinarians or registered veterinary nurses under the direct personal
supervision of a veterinarian will have access to the Schedule 2,3 and 4 medicines
Only registered veterinarians will have access to the Schedule 8 safe
6. Recording
Please indicate how records of administration and supply of medicines are maintained:
Schedules 2,3 and 4
Patient notes:
Yes
No
Schedule 8
Patient notes:
Yes
No
Schedule 8 register - HA14: Yes
No
How often is Schedule 8 stock balance checked?
10. Declaration
I,
provide full name
of:
provide full address
hereby declare:
i.
I am over 21 years of age.
ii.
The information contained in this application form to be true and correct.
iii.
I am aware that penalties apply under section 35 of the Poisons Act 1964 for providing
false or misleading information in this application.
iv.
I am familiar with the provisions of the Poisons Act 1964 and Poisons Regulations 1965
relevant to the poisons to which this application relates.
v.
As permit holder I am aware of my responsibility for the safe storage and use of poisons
and will ensure compliance with the Poisons Act 1964 and Poisons Regulations 1965,
and compliance with conditions placed on the permit.
vi.
I will notify the Department of Health if details on this form change including:
if the permit holder leaves employment or takes extended leave
if there is a change of premises or storage address
when additional poisons are required
Signature of applicant:
Date:
Poisons permit application Veterinary
practice
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Payment options
Application fee:
1 year: $240, 3 years: $360
Cheque or money order – made payable to: DEPARTMENT OF HEALTH
Credit card - American Express and Diners not accepted
Card type:
Mastercard
Visa
Name on card:
Amount :
$240
Card number:
Expiry date:
Signature of cardholder:
Date:
Direct debit to bank
Bank: Commonwealth Bank
BSB: 066 040
Amount:
$240
$360
Receipt Number:
Account number: 13300018
Payment date:
Submission
Please post completed form to:
Health Corporate Network
PO Box 8549
PERTH BUSINESS CENTRE WA 6849
Payment enquiries: 1300 367 132
$360