Action Plan | Melbourne Allergy Centre & Children’s Specialists (MACCS) Medical Group

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Call Us: 03 9345 6888

Action Plan Request

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

A $30 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?

Please select specialist

Dr Bella Shadur
Paediatric Allergist & Immunologist

Dr Dean Tey
Paediatric Allergist & Immunologist

Dr Ee Lyn Su
Paediatric Allergist & Immunologist

Dr Gabby Mahoney
Paediatric Allergist & Immunologist

Dr Jolene Fraser
Paediatrician with a Special Interest in Allergy

Dr Mark Taranto
Paediatric Allergist & Immunologist

Dr Marnie Robinson
Paediatric Allergist & Immunologist

Dr Paxton Loke
Paediatric Allergist & Immunologist

Dr Pei Ying Loo
Paediatrician with a Special Interest in Allergy

Dr Sabeena Selvarajah
Paediatric Allergist & Immunologist

Dr Sing-Jill Chow
Paediatrician with an Interest in Allergy

Dr Omega Leong
Paediatric Allergist & Immunologist

Dr Tim Brettig
Paediatric Allergist and Immunologist
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?*
- Cow’s milk
- Egg
- Soy
- Wheat
- Sesame
- Fish
- Shell fish
- Peanut
- Tree nuts
- Other
Please select
Please Select
- All (Check this if it is more than 4)
- Almond
- Hazelnut
- Walnut
- Pecan
- Brazil nut
- Macadamia
- Pistachio
- Pine nuts
- Cashew
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
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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
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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?
11. Do you need an Epipen script?
12. Do you need an Epipen script?
Do you need an Epipen script?*
- Yes
- No
13. Comments
12. Comments
12. Comments
11. Comments
Comments

Script Request / Delivery Method
A $30 fee is applicable. Please be advised we apply 1% surcharge to all of our card transactions.
01. Please send my script to.
Please send my script to.
- My Chemist
  (Script will be faxed or posted)
02. Your Chemist Details
Chemist Name*
Chemist Address*
Address (Line 2)
Suburb*
State*
Postcode*
Fax*

Action Plan Request/Summary
Your child's details:

First Name

Last Name

Date of birth

Edit

Family/Emergency contact:

First Name

Last Name

Work Phone

Home phone

Mobile phone

Email

First Name

Last Name

Work Phone

Home phone

Mobile phone

Email

Who is your child's allergy specialist?

Do you require a:

Which food allergens does your child avoid?

What is your child's approximate weight?

Which antihistamine does your child usually use?

Does your child have asthma?

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

Edit

Total

Item Action Plan Request $30

Item Epipen Script $10

Item Credit Card Surcharge $0.9

Total$30.9

Total$40.9

Payment Summary
Action Plan*
Price:
Epipen Script*
Price:
Credit Card Surcharge*
Price:
Total Payable
$ 0.00
Credit Card
Comments
This field is for validation purposes and should be left unchanged.

Getting to our practice

Our practice is situated directly next to the new Royal Children’s Hospital at 48 Flemington Road and is part of the Royal Children’s Hospital precinct.

MACCS Medical Group
Suite 1.1, Level 1
48 Flemington Road
Parkville Victoria 3052
View Google Map

Tel:03 9345 6888*
Fax:03 8374 3860*
Email:[email protected]

Travel Tips

Car Parking

Car parking is available at the Royal Children’s Hospital car park and also in surrounding streets- off street parking is available in Flemington Road and Gatehouse street but spots are metered (most 2 hours) and are limited.

Public Transport

There is a tram stop out the front of the 48 Flemington Road site. Trams 59 (from Elizabetth street) and 55 (from Williams street) stop almost immediately outside the practice.

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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 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

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

Action Plan Request

Script Request / Delivery Method

Action Plan Request/Summary

Your child's details:

Family/Emergency contact:

Total

Payment Summary

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