Patient Registration Form

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 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 1300 900 863.

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

Appointment Type

I am after *

Initial consult - $175.00*Follow up: $80.00Repeat script: $45.00

Please note:

If you have not had an initial consultation with a PhenixHealth doctor then your 1st appointment will be an “Initial Consultation”. Please do not choose ‘Repeat Script’ as it is a requirement of the TGA to conduct a thorough initial assessment.
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 book fee payment will be requested as part of the initial patient registration process.

Initial Consultation

For Medicare Card holders, the practitioner will Bulk Bill Medicare directly on your behalf following the consultation. The item # for this will vary. The Book fee is displayed above taken prior to a consultation and confirmed by your completion of this form.

For NON-Medicare Card holders the Book fee and the consultation fee will be the amount displayed above PLUS whatever the Medicare rebate would normally be for this consultation. Please allow up to $250.00 for the Initial Consultation.

Medications are not included.

Follow up consultation.

This consultation is often shorter than your initial consultation. The practitioner will review your treatment program and make recommendations where needed.

Medications are not included.

Repeat script consultation.

You may only need a repeat script in a brief consultation, so this is the option for you.

Please be mindful that the practitioner will review your medical records and may request an appointment. If this is the case, you will be informed.

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.

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.

Appointment time & date

Preferred appointment date and time *Please note this is subject to availability, we cannot always guarantee your chosen time and date. If not available we are able to organise another time or date for when it suits you.

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

Medicare/Pension/Private Health

Do you have a Medicare card? *

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

Do you have private health insurance? *

YesNo

Name of private health fund

Membership No.

Medical Info

Social Activity Info

Do you smoke cannabis? *

YesNo

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

What medication/treatment have you previously tried to treat your condition?

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

YesNo

What are your health goals with medicinal cannabis?

Help Us Find the Right Medical Practitioner for You

Do you prefer a male or female Medical Practitioner?

MaleFemaleDon't mind

When would you like your appointment? *

As soon as possibleWithin the next 2 weeks1 month+

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 medicinal cannabis is an unregistered medicine in Australia *

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 understand that my progress may be monitored by a registered nurse on behalf of Phenix Health and agree to receiving monitoring phone calls during weeks 1, 3, 8 and 16 of my treatment. *

I have read and agree to the Terms and Conditions of the CaptureCARE Telehealth Nursing Program. *

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 *

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).

Do you consent to our handling of your personal information in accordance with our Privacy Policy? *

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

Please complete the following payment prior to submitting your form *

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