Anesthetic Risk Assessment

First Name *
Last Name *
Contact Phone Number *
Postal Street Address *
Suburb *
Postcode *
State *
Do you have any allergies/sensitivities to Lidocaine, Tetracaine, Preilocaine or Benzocaine? If yes, what are they? *
Are you currently taking any of the following medications - Anti-Arrhythmic drugs or Sulfonamides? If yes, please list them. *
Have you used a local anesthetic before? *
What is the reason for using a local anesthetic? *
How many days do you expect to require treatment? *
Important information: Compounding Guidelines stipulate we must perform a risk assessment before we can supply any compounded product. By filling in this form you help us comply. The authorities have been aggressive towards many compounders shutting them down overnight for non compliance so we must abide by these in order to remain open. We must also consider the quantity being supplied as the authorities have been very strict with what they perceive to be an over supply so if you order a quantity that could be considered an over supply we will call you to discuss. Finally please only order for your own personal needs and not for any other individual.