Prescriber bag order · DocBag Express

Your details

These are printed on your order form.

Prescriber name

Street address

Suburb and state

Postcode

Phone number

Prescriber number

Your PBS prescriber number

Check your order

Please check this is right before you sign.

Item	Quantity

You will be signing this declaration I declare that, in accordance with the National Health Act 1953 and the National Health (Pharmaceutical Benefits) Regulations 2017, I have not exceeded the monthly maximum quantity allowed or placed any other order for any of the above prescriber bag supplies for the month preprinted on this form.

I understand that a paper prescriber bag order form is being completed on my instruction, and that my signature will be applied to it in ink as I sign.

Your copy is returned to you with your order.

Signed

Your order form has been signed and lodged. We will be in touch to confirm before dispatch.

Your details

Choose your items

Check your order

Signed

Your form

Sign here

Applying your signature