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Purchase order for scheduled drugs and/or scheduled poisons – Template June 2011
Unique order number
Purchase order for scheduled drugs and/or scheduled
Health (Drugs and Poisons) Regulation 1996
Name of licensed wholesaler of scheduled drugs and poisons:
Name and address of person authorised to obtain scheduled drugs and poisons:
Name and address of authorised person’s company / business / organisation:
Please supply the following:
Drug (generic name)/ Trade name
Form eg. amps,
Strength Quantity / Volume
Signature of authorised
person (or delegate)
Name and address of countersigning person (if applicable)*:
* Countersigning person is required where authorised person (or delegate) is NOT a doctor.
This is a generic template, the use of which is not mandatory. Other formats of purchase orders may be more suitable for certain
persons and they are acceptable, if all requirements for purchase orders in the Health (Drugs and Poisons) Regulation 1996 are complied
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