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

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 Anneke Engwerda
Paediatrician

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 Sylvie Picker-Minh
General & Developmental Paediatrician

Dr Omega Leong
Paediatric Allergist & Immunologist

Dr Tim Brettig
Paediatric Allergist and Immunologist

Dr Yoko Asakawa
General & Developmental Paediatrician
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?*
Zyrtec*

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
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

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
Other*
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

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

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

Call Us: 03 9345 6888

Action Plan Request

Script Request / Delivery Method

Action Plan Request/Summary

Your child's details:

Family/Emergency contact:

Total

Payment Summary

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

Upload & Crop Image