Form

Please complete all parts of this form and then press the SUBMIT button:

You will be required to enter all of your medications
An e-mail address is required
A copy of your submission will be sent to you for your records
You will receive a reminder when your next declaration is almost due

Submission Type *

Full Name *

First Name Last Name

Date of Birth

- Day - Month Year

Employee Number

You are choosing to re-submit data from the previous month. You must be certain that the medications you declared are the same as last month.

If you have taken any new medications in the last month you must 'Make a new Submission'.

To continue with a repeat submission using exactly the same declaration you had last month complete the verification section below and press the submit button.

What Site do you work at? *

If other what site do you work at? *

What Department do you work in? *

Department (If Other) *

What Company do you work for? *

Company Name (If Other) *

Supt Name or Perilya Representative name *

What type of medication are you declaring? *

Prescription Medications (please select all that apply) *

Prescription medications (If Other) *

Over The Counter Medications (please select all that apply) *

Over the counter medications (if Other) *

If you continue to take your medication, you will be required to re-enter all of your medications one month from the date shown below

Date of this Declaration

- Day - Month Year

Please add your e-mail address and mobile phone number below to recieve a copy of this submission straight to your inbox.

You MUST PROVIDE an e-mail address to recieve reminders as this is part of a verification process to send you information. If you do not add an e-mail address you WILL NOT BE ABLE TO COMPLETE YOUR MEDICAL DECLARATION

Would you like to receive a reminder notification? *

E-mail (you must add an e-mail address to get reminders) *

Mobile Ph:

Enter the message as it's shown *

Medication Declaration