Patient Details

Title *

First Name *

Last Name *

Address *

Street address *

City *

State *

Postcode *

Date of Birth *

Gender *

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

Email Address *

Are you of Aboriginal or Torres Strait Islander Origin? *

YesNo

Are you an adult aged 18 years or older? *

YesNo

Medicare, IHI & Concession

Medicare Number *We do not process payments through Medicare, we require your Medicare number to be able to provide patients with scripts.

Medicare Card Reference NumberIf you share your Medicare card with others, please write your individual reference number.

Medicare Card Expiry DateYYYY-MM

Concession CardIf you are a concession card holder please input your card number.

Concession Card TypeIf you are a concession card holder please input your card number.

Concession ExpiryYYYY-MM

General Practitioner Details

General Practitioner Name *Please write the name of your General Practitioner and/or regular Doctor.

General Practitioner Clinic Details *Include the clinic name where you visit your treating Doctor.

Medicinal Cannabis Questionnaire

Have you tried conventional medications with poor symptom control and/or intolerable side effects? *

YesNo

Do you have a chronic condition? *

YesNo

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.

List any symptoms you experience related to your health conditions – *

Do you have any allergies and/or adverse reactions? If yes, please list them – *

List all of your current medications and treatments for your current condition(s) – *Please list medication names and dosing, this is a mandatory question required by our doctors.

Do you have an unstable heart condition – e.g. unstable angina? *

YesNo

If you have ticked yes to this question, additional documentation may be required from a suitable healthcare practitioner.

Are you pregnant or breastfeeding? *

YesNo

Have you been diagnosed with Schizophrenia, or have a family history of Psychotic episodes personally or within your family? *

YesNo

If you have ticked yes to this question, additional documentation may be required from a suitable healthcare practitioner.

I am aware and understand the risks and complications associated with Medicinal Cannabis treatment, and I agree to follow my doctor’s recommendations with regards to dosing and report any adverse effects of Medicinal Cannabis including – changes in the level of sedation, lethargy, fatigue, dry mouth, nausea, vomiting, diarrhea, drowsiness, dizziness, disorientation, agitation, balance problems, changes in memory, paranoid delusions or hallucinations. *

YesNo

I agree that I will not use any other forms of cannabis other than what is prescribed by my doctor – including any illicit forms of cannabis (marijuana). *

YesNo

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.

Health Summary Upload

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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.

Health Summary Consent

Authorization for Use/Disclosure of Information –

I consent to sharing my health care records in the form of a Health Summary including the following details, if applicable – medical history, current and previous medications, and any comments or concerns regarding patients health.

Recipient: I authorize my health care information to be released to Mi Dispensary to be sent via. e-mail to info@midispensary.com.au.

Information to be disclosed: I authorise the release of the above information pertaining to my personal medical records.

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

Patient Full Name

Date

Patient Signature

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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.