Patient Details

Please include the area code if you are inputting a home phone number.

Medicare, IHI & Concession

We do not process payments through Medicare, we require your Medicare number to be able to provide patients with scripts.
If you share your Medicare card with others, please write your individual reference number.
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If you are a concession card holder please input your card number.
If you are a concession card holder please input your card number.
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General Practitioner Details

Please write the name of your General Practitioner and/or regular Doctor.
Include the clinic name where you visit your treating Doctor.

Medicinal Cannabis Questionnaire

A chronic condition (also known as chronic disease or chronic illness) is a health condition or disease that is persistent or otherwise long-lasting in its effects or a disease that comes with time. The term chronic is often applied when the course of the disease lasts for more than three months.
Please list medication names and dosing, this is a mandatory question required by our doctors.
If you have ticked yes to this question, additional documentation may be required from a suitable healthcare practitioner.
If you have ticked yes to this question, additional documentation may be required from a suitable healthcare practitioner.

Baseline Assessment Forms

Health Summary Form

Upon completion of this form, you will be redirected to book your appointment. Once your appointment time is confirmed, you will be required to complete Baseline Assessment Forms.

For patients aged 25 years and younger we will require a Health Summary and/or relevant Health Documentation pertaining to your individual health concerns.

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If you already have your Health Summary provided by your General Practitioner or Referring Doctor, please upload it here. Alternatively, if you wish for us to obtain your Health Summary on your behalf, please tick the checkbox below.

I declare all answers provided herein are true and accurate to the best of my knowledge and belief.

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Important:  Consultation with a Doctor does NOT guarantee prescriptions for medicinal cannabis medications. As per the Therapeutic Administration Guidelines, this treatment option is a second-line treatment modality where all other treatments have failed. Provision of prescriptions is at your treating Doctor's discretion. 

Important: Completion of this form does not reflect any appointment bookings. Once your form is received by our team, you will be redirected to an appointment scheduling and payment processing page. Should you have any questions, please contact us directly at info@midispensary.com.au or call us on 1300 MiTIME (1300 648 463). 

MiDispensary is not an Emergency Service and if immediate treatment is required you should contact the nearest Emergency Department or call 000.