Patient Registration Form

Eligibility

It is expected (by the TGA) that patients have trialled clinically appropriate treatment options that are included in the ARTG before applying to access an unapproved medicinal cannabis product under the SAS. In WA, two PRESCRIBED medications should be tried whereas one is sufficient in all other states.

Sorry. You have not passed the basic criteria to be eligible for a medicinal cannabis script.

Please ensure you have:

  • Had your condition(s) clinically diagnosed by a physician

  • Tried at least one (two for WA patients) conventional medication to manage the symptoms of your condition(s)*

When you have satisfied the above criteria, feel free to try again.

If you would like to discuss, speak to your personal doctor contact 13BALNCE (1300225623).

*Conventional – prescribed by a doctor and dispensed by a pharmacist – not over the counter.


PLEASE NOTE: As soon as your payment is cleared our Medical Receptionists will call within 1 hour to confirm your details and book your appointment.

Appointment Type

Please note: 

  • If this is your first time seeing a Balnce healthcare practitioner, you must select “Initial Consultation”. Please do not choose ‘Repeat Script’ as it is a legal requirement of the TGA that a thorough initial assessment is conducted first. Our health care practitioners comprise of APHRA registered doctors and nurse practitioners who have all completed additional training and are skilled in the area of medicinal cannabis therapy. All prescribing is in accordance with the latest TGA prescribing recommendations.

  • If you have previously consulted with another GP then please mention their name so we can share with your consent the required test results if necessary.

  • The consultation payment will be requested as part of the patient registration process.

Initial Consultation

  • All consultations are privately billed.

  • Medications are not included.

Follow up consultation. 

  • Please do not choose ‘Repeat Script’ as it is a legal requirement of the TGA that a thorough initial assessment is conducted first. Our health care practitioners comprise of APHRA registered doctors and nurse practitioners who have all completed additional training and are skilled in the area of medicinal cannabis therapy. All prescribing is in accordance with the latest TGA prescribing recommendations.

  • If you have previously consulted with another GP then please mention their name so we can share with your consent the required test results if necessary.

  • The consultation payment will be requested as part of the patient registration process.

Repeat script

  • You can only have a repeat script if you have had a 'follow up consult with a healthcare professional. 

  • Repeat Script booking is only for exactly what you have previously had prescribed. You do not speak to the Healthcare professional. Changes to scripts need a consultation with a healthcare professional and you must pay $80 for a follow up consult.

  • Please do not choose ‘Repeat Script’ as it is a legal requirement of the TGA that a thorough initial assessment is conducted first. Our health care practitioners comprise of APHRA registered doctors and nurse practitioners who have all completed additional training and are skilled in the area of medicinal cannabis therapy. All prescribing is in accordance with the latest TGA prescribing recommendations.

  • If you have previously consulted with another GP then please mention their name so we can share with your consent the required test results if necessary.

  • The consultation payment will be requested as part of the patient registration process.



Follow up

You have selected the request type: Follow up. 

In order to receive a follow up consultation you must have used our service previously. If this is correct please select next, if you have not received an initial consult before please select the 'previous' button and choose the correct option.

Repeat script

You have selected the request type: Repeat script. 

In order to receive a repeat prescription you must have used our service previously. If this is correct please select next, if you have not received an initial consult before please select the 'previous' button and choose the correct option.


Personal Info

This information is required if you are booking an appointment for Medicinal Cannabis. Due to the current legislation all this information is required to ensure the Health Practitioner can provide you with all relevant information regarding the treatment / procedure.

Document Request

Browse
If you have a specific document to be completed by the HCP, please upload it here.

Medicare/Pension/Private Health

Your Medicare Number is used to verify your identity within our eScript software. If you do not provide your card details or do not have a Medicare card, you will not be eligible to receive an eScript. You will need to nominate a pharmacy for your manual prescription to be sent too. Only verified patients can receive eScripts.

If you use Alias please write the Alias name & surname

The reference number is the number next to your name on your Medicare card.

Medical Info

Social Activity Info

Select multiple if you are using multiple products.

Symptomatic Relief and Side Effects

Numbers and '.' only.

Patient Treatment Goals

Repeat Script Request

Repeat script consultation. If you only need a repeat of an existing script, no other concerns or questions, then you can select the $45 repeat option. Medications are not included.

Help Us Find the Right Medical Practitioner for You

*This may be subject to availability

Consent

In order to preceded with my telehealth appointment.

We are committed to protecting your privacy and know it is important for you to understand how your information is handled.

In submitting the information contained in this form,:

Privacy and Terms

We are committed to protecting the confidentiality of your personal information and health records. (You can access our Privacy Policy on our website, or by asking us for a copy).

Medicinal Cannabis is a restricted S8 medication and a part of the TGA application process the Health Care Practitioner may request additional information from you before prescribing. Such as a Health Summary, Specialist Clearance Letter or Pathology in order to fully review your medical history. This can be emailed to support@balnce.health Admin staff do not access your medical file when booking appointments and, if you have not supplied the required paperwork, the practitioner may cancel your scheduled appointment until such time as you supply the required paperwork.

At Balnce we work hard to provide an excellent service to our patients. In saying that, we have a zero-tolerance policy towards any verbal abuse towards our staff. This includes shouting, swearing, or connecting through private social media or making unnecessary remarks. Abusive language affects our staff’s well-being and they have the right to come to work and not feel intimidated or frightened. Abusive, excessive and aggressive behaviour will result in you being asked to attend another practice for treatment.

Please be mindful that our practitioners will call you as close to your appointment time as possible. Sometimes the patient prior to your consultation may take longer than expected. If you are unable to attend your appointment please allow 24 hours’ notice to reschedule and this will not incur a fee. Our practitioners calendars can be very busy and this allows for another patient on a waitlist an appointment. If you miss your allocated appointment, your practitioner will attempt to call you twice before asking our reception team to follow up and reschedule your appointment. This will incur a fail to attend fee of $100.00.

To improve patient experience and script convenience the clinic uses eScript software. As part of the eScript cross-checking process, it identifies if you were prescribed 'monitored medicines' issued by another health care practitioner and may reject scripts based on a matching criteria. The rejection of a script occurs only after it is submitted at the end of a consultation.

Communication

Payment

If you choose to use PayPal e-Cheque as your payment option, please be mindful the funds may take up to 6 days to clear. Once received the team will contact you to arrange your doctor’s consultation.

PLEASE NOTE: As soon as your payment is cleared our Medical Receptionists will call within 1 hour to confirm your details and book your appointment.

Signature

Draw signature|Type signatureClear