EP002

EP002 - Application for Consignment Account (PBS)

Doctor Information

If the clinic is intending to purchase products scheduled under the Poisons and Therapeutic Good Act 1966, the signatory must be a registered Medical Practitioner and his/her AHPRA registration number must be provided, along with a hard copy of the Medical Practitioner License.

The Encapsulate Pharma Account will be registered in the Doctor’s name

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Go to https://www.ahpra.gov.au/registration/practitioner-services.aspx - Prescribing Doctor will need to Log into their user account using user ID and password. Under the "Registration" tab click on "Download Registration Certificate", the current Certificate of Registration will be displayed as a PDF document which can be saved to your computer and selected after selecting "Browse" here.

Please provide Encapsulate Pharma with an email address to which a username and password setup link will be sent to enable you to order Xeomin via the Encapsulate Pharma Order Portal.  This email should be only accessible by the Account Holder - named on the Medical Registration certificate provided above. 

Note. This email will only be used for the purpose of providing username and password setup for the Order Portal and will not be used to contact you for marketing purposes.

You are authorising the creation of this account in your name, as the authorised Medical Practitioner for this clinic

  • As a Medical Practitioner, the delivery address(es) stated on this form is/are your current place of practice

  • Invoices for the delivery of the product will be issued under your name at this clinic's address (your authorised practioner's practice address)

  • All product will be delivered to this address (your authorised practitioner's practice address). In the case of Xeomin PBS Consignment Stock this invoice shall be nil value.

  • You agree that you are appropriately authorised and insured, and will comply with all applicable Federal and State territory laws and regulations applying to products containing Schedule 4 substances, and these are supplied to you on the basis that you will do so.

It is the responsibility of the prescribing doctor to advise Encapsulate Pharma immediately if there are any changes in regards to your clinic details or clinics for which you are listed as the prescribing doctor.

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Account Commencement Order

If you wish to place an initial order please fill in the quantity of vials of Xeomin 100U required on PBS consignement and these will be delivered to the practice address provided below once your application has been validated and approved by Encapsulate Pharma 

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This form can be signed using a mouse or via finger/pencil on a touch screen. You can save and email the completed document to the signatory for signing on their computer or mobile phone followed by submission. If you are unable to electronically sign please print, hand sign and email the scanned copy to customerservice@encapsulatepharma.com


Company / Business Information

Account Contact - Consignment Management and Returns Reporting

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XEOMIN® AND MERZ logos are registered trademark of Merz Pharma GmbH & Co. KGaA.Therapeutic indications distributed in Australia by Encapsulate Pharma Pty Ltd (ABN 80 640 718 289) 34 Thurso Street, Malvern East, Victoria, Australia. Copyright © 2020.All rights reserved. Tel: +61 3 9568 4975 Web: www.encapsulatepharma.com               

ENCAP-XEO-AU-[1029] Date of Preparation: DEC 2022