Victorian ORT Prescribers: Join our referral database

We will add your details to the referral database our counsellors use to connect clients with appropriate ORT prescribers. Your information will be held in our internal database and will not be directly available to the public.

This form is for medical professionals licensed to prescribe ORT in Victoria only.

Prescriber Type

Name *

Email *

Clinic Name *

Address *

Suburb *

Phone Number - Clinic *

Phone Number - Mobile

Other Email Address(es) (if relevant)

Available Pharmacotherapies

Buprenorphine (Subutex)

LAIB (Long Acting Injectable Buprenorphine)

Methadone

Suboxone

Vacancy Status

Agency Days/Hours

Do you offer bulk billing?

Fees

Do you accept temporary transfers?

Do you accept prison release clients?

Intake procedures

Other information

I agree to join the database.