Patient Registration and Booking Form

Initial Details

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

Do you reside in Australia? *

YesNo

Appointment Type

Type of practitioner *

General Practitioner (GP)

I am after *

Initial consult - $125.00*Check-In: $75.00External documentAdditional payment: $40.00

I am after *

Medical certificate/travel letter - $60.70

I am after *

Medical certificate/travel letter - $19.95Letter of recommendation/GP letter - $45.00

Please note:

If this is your first time seeing a CannaTelehealth healthcare practitioner, you must select “Initial Consultation”. Please do not choose ‘Check-In’ 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.
You can view our billing policy here.

Initial screening consultation

Start your journey by discussing your plans with a Nurse Practitioner
Consult is bulk billed - you must have a Medicare card
You cannot receive medications or TGA applications during this consult

Initial Consultation

All consultations are privately billed. These could take between 10-30 mins depending on your medical history and conditions. Always ask the HCP if you need more explanation.
Medications are not included.

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.

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 *

Mobile phone *

Email *

Address *

Postcode *

City / Suburb

State

Medicare/Pension/Private Health

Do you have a Medicare card? This is necessary in order to povide you with an escript to your phone or email *

YesNo

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 *

If eligible for Medicare, DVA or concessional billing do you give permission to bill? *

YesNo

I assign my right to benefits to the health professional who rendered the services. *

YesNo

Do you have a Pension/Health Care card? *

YesNo

CRN no.

Expiry date

Medical Info

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

What chronic condition/s have you been diagnosed with? *

What are your current symptoms? *

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:

Have you been prescribed Medicinal Cannabis by another clinic? If so which clinic? This is important as it may impact the TGA approving your script. *

Social Activity Info

Do you smoke/use cannabis? *

YesNo

Do you currently take Medicinal Cannabis? Would you like to change products? If so, why?

If you have been prescribed Medicinal Cannabis have you been to a different medical cannabis clinic? If so which one?

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

What are your current medication? *

Listed below

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?

Help Us Find the Right Medical Practitioner for You

Pharmacy consent

We use partner pharmacies that manage all of your prescriptions and repeats. They will set you up accounts for you to securely pay for your medication along with reordering when each script is due. They will call every new patient when we send your e-script to the pharmacy and make sure to answer any questions you may have about price, strength, dosage, side effects or anything related to their service around medical cannabis.

I consent for the pharmacy to contact me when they receive my script.

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, you:

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 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 long term side-effects of medical cannabis are unknown *

Please note that medical cannabis is a Schedule 8 medication and it is a requirement in Australia that it be entered on Q script, NSW safe script, VIC safe script, script check SA and Canberra script. So if you have been dispensed a medical cannabis product previously by another health professional from another service we may legally not be able to issue a script for you.

*

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 consent to CannaTelehealth handling of personal information in accordance with their Privacy Policy? *

At CannaTelehealth 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 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 and aggressive behaviour will result in you being asked to attend another practice for treatment.

I agree with CannaTelehealth 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 CannaTelehealth reschedule and fail to attend appointment fees. *

Catalyst by honahlee is an independent medicinal cannabis product education, insights and feedback platform. Using Catalyst you’ll be able to access detailed information about the products you’ve been prescribed and other potential products for your treatment plan. By checking this you agree receive an invite to Catalyst via email.

PRIVACY COLLECTION NOTICE

This Privacy Collection Notice describes how PHENIX HEALTH PTY LTD (ABN 22 607 822 266) ( we , us or our ) collects and handles your personal information when you sign-up to do business with us. We collect personal information from you and from third parties (such as our cookies and analytics providers) so that we can do business with you and for related purposes set out in our Privacy Policy, available on our website (or on request).

We may disclose this personal information to third parties, including our personnel, related entities, any third parties engaged by us and acting on our behalf and as otherwise set out in our Privacy Policy.

We store personal information in Australia. Where we disclose your personal information to third parties, those third parties may store, transfer or access personal information outside of Australia.

If you do not provide your personal information to us, it may affect our ability to do business with you.

Please see our Privacy Policy for more information about how we collect, store, use and disclose your personal information, including details about overseas disclosure, access, correction, how you can make a privacy-related complaint and our complaint-handling process.

If you have questions about our privacy practices, please contact us by email at: info@cannatelehealth.com.au. By providing your personal information to us, you agree to the collection, use, storage and disclosure of that information as described in this privacy collection notice.

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

Signature

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

Signature

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Today's date

Payment

If you have selected 'Initial eligibility screening consultation' you are not required to pay and can continue to submit the form. If you do not have a Medicare card you are not entitled to 'Initial eligibility screening consultation'

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.

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