These application forms are for a Health Service Permit, which is a permit to purchase medicines for use in treating
the patients of a healthcare service, including imprest medicines for urgent treatment at residential aged care
facilities. Please use the form that best describes the type of healthcare service you provide.
If you cannot find a suitable form on the list, please contact the Medicines and Poisons Regulation Branch for advice
by phoning 9222 6883 or emailing MPRB@health.wa.gov.au.
Ambulance service
You need to use this application form if you are a business and you want to purchase Schedule 2,3 4 or 8 medicines
because you are operating a service which provides ambulances and/or paramedical staff for emergency services,
events, training or patient transfers:
Application form for a new permit for an ambulance service (Word 401KB).
Ambulance services will be issued with a Health Service Permit.
If you have an existing permit for an ambulance service and you require changes to the permit, you need to use this
form:
Application form to change an existing permit for an ambulance service (Word 368KB).
Cosmetic procedure clinic
You need to use this application form if you are a business that wants to administer cosmetic injections:
Application form for a new permit for a cosmetic procedure clinic (Word 225KB).
Cosmetic procedure clinics will be issued with a Health Service Permit.
Please read the Cosmetic
Procedure Clinic Guideline (Word
366KB) about who should apply
for this type of permit.
Please note: if your medical practice provides a more comprehensive service with a medical practitioner on site
whenever patients are being treated, the Application form for a new permit for a medical/dental practice (Word 395KB) should be
used.
If you have an existing permit for a cosmetic procedure clinic and you require changes to the permit, you need to use
this form:
Application form to change an existing permit for a cosmetic procedure clinic (Word 326KB).
First aid
You need to use this application form if you are a first aid provider at a workplace and you want to purchase
Schedule 2 and 3 medicines (pharmacy over the counter products) for use at that workplace when providing first
aid to staff and/or clients:
Application form for a new permit for a first aid service (Word 297KB)
The first aid provider will be issued with a Health service Permit.
If Schedule 4 (prescription only) or Schedule 8 (controlled drugs) are required, please use the Application form for a new permit for a medical treatment service (Word 401KB).
If first aid treatment is required at events and Schedule 2 and 3 medicines will be transported from the storage
address to these events, please use the Application form for a new permit for an ambulance service (Word 401KB).
If you have an existing permit for a first aid service and you require changes to the permit, you need to use this
form:
Application form to change an existing permit for a first aid service (Word 300KB).
Immunisation service
You need to use this application form if you are an immunisation provider and you want to purchase vaccines for use
at specific sites or as part of a mobile service (such as a service that holds vaccine clinics at workplaces):
Application form for a new immunisation service (Word 366KB).
Immunisation services will be issued with a Health Service Permit.
If you have an existing permit for an immunisation service and you require changes to the permit, you need to use
this form:
Application form to change an existing permit for an immunisation service (Word 325KB).
Medical/dental practice
You need to use this application form if you are a medical or dental practice or private hospital, including a day
hospital, and you want to purchase medicines for use at the practice or hospital:
Application form for a new permit for a medical/dental practice (Word 395KB).
Please note: a permit is only required where you want to pool medicines for use by all practitioners.
Individual prescribers are authorised to purchase medicines under their own name and use those medicines to treat
their own patients. This includes medicines provided to medical practitioners and nurse practitioners as Pharmaceutical Benefits Scheme (PBS) | Prescriber Bag
Supplies (external site).
Medical and dental practices and private hospitals will be issued with a Health Service Permit.
If you have an existing permit for a medical or dental practice or a private hospital and you require changes to the
permit, you need to use this form:
Application form to change an existing permit for a medical/dental practice (Word 356KB).
Medical treatment
You need to use this application form if you are a medical business and you want to purchase medicines for providing
medical treatment services to third party sites, such as mining and resource industry sites:
Application form for a new permit for a medical treatment service (Word 393KB).
Medical treatment businesses will be issued with a Health Service Permit.
If you have an existing permit for a medical treatment service and you require changes to the permit, you need to use
this form:
Application form to change an existing permit for a medical treatment service (Word 367KB).
Residential care
You need to use this application form if you are a residential care facility and you want to purchase imprest (also
called stock supply) medicines for the facility:
Application form for a new permit for a residential care facility (Word 394KB).
Residential care facilities will be issued with a Health Service Permit.
A permit is not required for medicines that have been dispensed for individual residents by a pharmacy.
If you have an existing permit for residential care and you require changes to the permit, you need to use this form:
Application form to change an existing permit for a residential care facility (Word 355KB).