Slade Pharmacy Patient Co-payment Form

For the Patient

From 1st September 2015, new government legislation requires a prescription be written for PBS botulinum toxin.
It also requires the patient to pay the standard co-payment fee (either $6.10 for concessional patients or $37.70 for
non-concessional patients). The co-payment collection will be managed by Slade Pharmacy in line with individual
Safety Net thresholds. To ensure that the dispensing and billing of your medication is correct, it is important that you
provide all required information on this form. Once completed and signed, this form will be sent to Slade Pharmacy by
your Doctor.

Additional information regarding Slade Pharmacy and payment options can be provided by your Doctor.

Patient’s Details

Mr Mrs Miss Ms Other DOB / /

Family Name First Name

Address Postcode

Medicare Number

Concession/DVA/Safety-Net details

Co-payment authorisation
I hereby acknowledge that I will receive a co-payment bill from Slade Pharmacy in the mail and I accept the
PBS co-payment terms and conditions.

Patient’s Signature Date / /

IMPORTANT: please complete all fields on this form to ensure that Slade Pharmacy can correctly bill for
the PBS co-payment in accordance with Safety Net thresholds.

For the Doctor

Return completed co-payment form to Slade Pharmacy

Email to: dysport@slade.net.au Fax to: (03) 9565 4488

Contact Person: Peter Kebernik Phone: Slade Procurement (03) 9565 4483

The information collected on this form is for the purpose of managing your safety net details and for co-payment
collection. For further information about Slade’s privacy policy please email privacy@slade.net.au