Action Plan Request

Your action plan and script will be issued within 7 business days.

A $40 fee is applicable. Please be advised we apply 1% surcharge. Please note, If your child is not a patient of MACCS Medical Group we will not be able to issue you an action plan and/or script

Please complete the following details for your child's action plan.

01. Your child's details:

Patient First Name*

Patient Last Name*

Date of birth*

02. Current photo of your child:

Current photo of your child*

Accepted file types: jpg, png, gif, Max. file size: 5 MB.

03. Family/Emergency contact:

First Name*

Last Name*

Work Phone

Home phone

Mobile phone*

Email*

03.1 Other Family/Emergency contact:

First Name*

Last Name*

Work Phone

Home phone

Mobile phone*

Email*

04. Who is your child's allergy specialist?

Who is your child's allergy specialist*

05. Do you require a:

Do you require an:*

06. Which food allergens does your child avoid?

Which food allergens does your child currently avoid?*

Please select

Please Select

Other Food Allergens

07.What is your child's approximate weight?

What is your child's approximate weight?*

08. Which antihistamine does your child usually use?

Which antihistamine does your child usually use?*

Claratyne liquid (loratadine 5 mg per 5 mL)*

Claratyne chewable tablets (loratadine 5 mg)*

Claratyne tablets (loratadine 10 mg)*

Claratyne DES liquid (desloratadine 2.5 mg per 5 mL)*

Desonex Allergy tablets (desloratadine 5 mg)*

Telfast liquid (fexofenadine 6 mg per mL)*

Telfast tablet (fexofenadine 120 mg)*

Telfast tablet (fexofenadine 180 mg)*

Zyrtec Oral Drops (cetirizine 2.5 mg per 5 drops)*

Zyrtec Liquid (cetirizine 5 mg per 5 mL)*

Zyrtec chewable tablets (cetirizine 5 mg)*

Zyrtec tablets (cetirizine 10 mg)*

Antihistamine	Formulation (Website drop down list 1)	Dose (Website drop down list 2)	Action plan wording (As displayed on action plan)
Zyrtec (cetirizine)	Zyrtec Oral Drops (cetirizine 2.5 mg per 5 drops)	Children 1-3 years (up to 14 kg): 4 drops Children 3-5 years (14-18 kg): 5 drops Children 5-6 years (18-22 kg): 6 drops Children 5-6 years (22-26 kg): 7 drops Children 5-6 years (26-30 kg): 8 drops Children from 7 years (over 30kg): 10 drops	Zyrtec Oral Drops: 4 drops Zyrtec Oral Drops: 5 drops Zyrtec Oral Drops: 6 drops Zyrtec Oral Drops: 7 drops Zyrtec Oral Drops: 8 drops Zyrtec Oral Drops: 10 drops
Zyrtec (cetirizine)	Zyrtec Liquid (cetirizine 5 mg per 5 mL)	Children 1-3 years (up to 14 kg): 2 mL Children 3-5 years (14-18 kg): 2.5 mL Children 5-6 years (18-22 kg): 3 mL Children 5-6 years (22-26 kg): 3.5 mL Children 5-6 years (26-30 kg): 4 mL Children from 7 years (over 30kg): 5 mL	Zyrtec Liquid: 2 mL Zyrtec Liquid: 2.5 mL Zyrtec Liquid: 3 mL Zyrtec Liquid: 3.5 mL Zyrtec Liquid: 4 mL Zyrtec Liquid: 5 mL

Adults and children 6 years and over. Use as long as needed.
Tablets should be chewed and not swallowed whole.

Age	How often
Adults and children over 12 years	Chew 2 tablets every 24 hours as necessary

This field is hidden when viewing the form

Claratyne*

Children 1-2 years	2.5 mL; once daily as necessary
Children 2-12 years: Up to 30kg Over 30 kg	5 mL; once daily as necessary 10 mL; once daily as necessary

Children’s Claratyne® Bubblegum Chewables:

Children 2 to 9 years of age	1 tablet; once daily as necessary
Adults and Children 9 years and over	2 tablets; once daily as necessary

Claratyne® Tablets

Adults and Children 12 years and over

1 tablet; once daily as necessary

For Hayfever (Allergic Rhinitis)

Age	How much	How often
Children 1 – 5 years	2.5 mL	Every 24 hours
Children 6 – 11 years	5 mL	Every 24 hours
12 years and over	10 mL	Every 24 hours

For Hives

Age	How much	How often
Children 6 – 11 months	2 mL	Every 24 hours
Children 1 – 5 years	2.5 mL	Every 24 hours
Children 6 – 11 years	5 mL	Every 24 hours
12 years and over	10 mL	Every 24 hours

How long is this product to be taken for?

Symptoms present for	Use
Less than 4 days a week or less than 4 weeks a year	Until symptoms have resolved
More than 4 days a week and more than 4 weeks a year	May continue during allergy exposure

This field is hidden when viewing the form

Telfast*

Shake well before use.

For	Age	Quantity	How Often
Itchy skin rash/hives	6 - 23 months	2.5mL	Twice daily as required
Itchy skin rash/hives & hayfever allergies	2 - 11 years	5mL	Twice daily as required

After closing, check the child resistant cap mechanism is engaged - this is confirmed if cap clicks when turned anti-clockwise.

Telfast 120mg Tablets – Hayfever Relief

Age	Quantity	How often
Adults and Children from 12 years	1 Tablet	Daily as required

Telfast 180mg Tablets – Hayfever Allergy Relief

Age	Quantity	How often
Adults and Children from 12 years	1 Tablet	Daily as required

This field is hidden when viewing the form

Other*

This field is hidden when viewing the form

Dose required

09. Adrenaline autoinjector prescribed?

Adrenaline autoinjector prescribed?*

10. Does your child have asthma?

09. Does your child have asthma?

Does your child have asthma?*

Yes
No

10. Do they have asthma symptoms occuring 1x/week or more?

11. Do they have asthma symptoms occuring 1x/week or more?

Does your child have asthma symptoms occurring 1x/week or more?*

Yes
No

if Yes, we strongly recommend an asthma review by your GP or allergy specialist

10. Do you need an Epipen script?

11. Do you need an Epipen script?

12. Do you need an Epipen script?

Do you need an Epipen script?*

Yes
No

A $10 fee is applicable for the script. Please be advised we apply 1% surcharge to all of our card transactions.

Action Plan

Action Plan Request

Action Plan Request/Summary

Your child's details:

Family/Emergency contact:

Payment Summary

Action Plan

Action Plan Request

Action Plan Request/Summary

Your child's details:

Family/Emergency contact:

Payment Summary

Upload & Crop Image