Med Dec

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

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