Patient Registration Form

Are you an existing Balnce patient or a new Balnce patient? *

Existing Balnce patientNew Balnce patient

Eligibility

Do you suffer from a chronic health condition that has lasted more than 3 months? *

YesNo

Have you tried conventional treatments for your condition? *

YesNo

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.

Do you reside in Australia? *

YesNo

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

I am after *

Initial consult - $125.00*

I am after *

Follow up: $80.00Repeat script: $45.00External document

Document type *

Medical certificate/travel letter - $19.95Letter of recommendation/GP letter - $45

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.

First name *

Last name *

Preferred name

Date of birth *

Gender

Is English your first language?

YesNo

Ethnicity

ATSI *

AboriginalTorres Strait IslanderNone of the above

Mobile phone *

Email *

Address *

Postcode *

City / Suburb

State

Document Request

Please provide details of your document request *

Document to be viewed/signed?

Browse

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

Medicare/Pension/Private Health

Do you have a Medicare card? *

YesNo

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.

Do you use a different name in your Medicare card?

YesNo

If you use Alias please write the Alias name & surname

Medicare first name

Medicare surname

Medicare card no. *

Medicare reference no. *The reference number is the number next to your name on your Medicare card.

Medicare expiry *

Do you have a Pension/Health Care card? *

YesNo

CRN no.

Expiry date

Do you have private health insurance? *

YesNo

Name of private health fund

Membership No.

Medical Info

If you were referred to our Clinic, please let us know by whom:

Do you consent for your regular GP to be notified of your treatment with our medical practitioner?

YesNo

If you are keen to share your medical information with your regular GP, please provide their details:

Social Activity Info

Do you smoke/use cannabis? *

YesNo

Symptomatic Relief and Side Effects

How often do you smoke cannabis? *

Do you smoke nicotine? *

YesNo

How often do you smoke nicotine?

Do you drink alcohol *

YesNo

How often do you drink alcohol?

Patient Treatment Goals

Are you currently taking medication? *

YesNo

Medication Name

Frequency

Dosage

Have you previously tried any medication/treatment to treat your condition? *

YesNo

Medication/treatment name

Frequency

Dosage (if applicable)

Have you had to stop previous medication due to severe side effects?

YesNo

What side effects did you experience for each medication?

What are your health goals with medicinal cannabis?

Repeat Script Request

Please type the medications that require a repeat scriptRepeat 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

Do you prefer a male or female Medical Practitioner?

MaleFemaleDon't mind

Preferred Health Care Professional?*

Nurse PractitionerGP

*This may be subject to availability

When would you like your appointment? *

As soon as possibleWithin the next 2 weeks1 month+

Other

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,:

I understand that medicinal cannabis is an unregistered medicine in Australia and long-term side-effects of medicinal cannabis are unknown. *

Driving with THC in the system is ILLEGAL in most Australia states and territories and may be detected at random roadside testing, as well as that a legally issued medical prescription does not provide protection from prosecution under these laws. I understand that I must not drive or operate heavy machinery whilst taking medicinal cannabis containing THC. I understand that a legally issued prescription does not provide a defence to such an offence *

I understand the risks and complications associated with medicinal cannabis treatment. I agree to follow my doctor's recommendation regarding dosing. I agree to report any adverse effects I experience from taking medicinal cannabis, including but not limited to changes in the levels of sedation, lethargy, fatigue, dry mouth, nausea, vomiting, diarrhoea, drowsiness, dizziness, disorientation, agitation, balance problems, changes in memory, paranoid delusions, or hallucinations *

I understand that medicinal cannabis might interact with my other medications, and may need to be adjusted accordingly *

I agree to attend regular follow-up consultations as directed by my doctor *

If I proceed with treatment, I agree to notify my prescribing doctor or Nurse Practtioner that I am being treated with medicinal cannabis *

I declare that all answers in this Consent Form are true and correct to the best of my knowledge and belief *

I understand the prescribing Healthcare Professional is required to report my treatment outcomes to the TGA and prescribing quantities will be monitored by State based safe script reporting. *

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).

I understand the Practitioner may request additions supporting information in order to proceed with treatment. Without this information appointments may be cancelled
*

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.

I consent to Balnce's handling of personal information in accordance with their Privacy Policy? *

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.

I agree with Balnce's Zero-Tolerance policy *

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.

I agree with Balnce’s reschedule and fail to attend appointment fees. *

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.

I understand if I have scripts with another health care practitioner for a similar medication, my new script may be rejected. I also understand that the health care practitioner is unaware at the time of the consultation and in the event this occurs, I forfeit my consultation fee. *

Communication

I would like to be kept up to date with the latest information about medicinal cannabis * *

YesNo

I consent to receiving SMS appointment reminders, messages and emails *

YesNo

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 complete the following payment prior to submitting your form *

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

I confirm that above information I have provided is true, complete and accurate. *

Signature

Draw signature|Type signatureClear

Today's date

Save and Complete Later