New Patient Form

Becoming A Patient –

Complete our New Patient Form below.
If you are aged 50 years or older, we will require a Health Summary and/or relevant Health Documentation.
Book your Initial Consultation with our MiDispensary practitioner, and pay for your appointment.
Complete your Baseline Assessment Forms, these will be emailed to you after you book your appointment.
Have your Initial Consultation with our MiDispensary practitioner, and organise your follow up consultations.

Appointment Fees & Inclusions –

MiDispensary has *LIMITED TIME REDUCED FEES* until end of April 2024 as outlined below –

Initial Consultation – Initial Consultations for new patients are $40.20 + processing fees, includes:
- Consultation with a MiDispensary Doctor, e-scripts and Medication Review with a MiDispensary Nurse.
Follow Up Consultation – Existing patient appointment fees are $40.20 + processing fees, includes:
- Consultation with a MiDispensary Doctor and Nurse, and e-scripts.
Script Rewrite – For existing patients requesting adjustments to current scripts where Doctor has advised no consultation is required to update or adjust prescriptions, where patients have had an appointment within six months. Fees are $20.00 processing fee, includes:
- Amendment to current prescriptions as requested and/if approved by treating Doctor.

Please note, appointment fees DO NOT cover the cost of your medication.

FAQs –

What is a Health Summary? A health summary is an overview of a patients medical history outlining:
- Current and previous health concerns.
- Immunisation history.
- Allergies and reactions to medications.
- Current and previous medications.
Where can I obtain my Health Summary? Your general practitioner will be able to provide you with your health summary. Simply contact their medical practice to ask it be provided to you, clinical administrative fees may apply. Alternatively, if you are using the MyHealthRecord, you can obtain a Health Summary from your myGov account.
Can MiDispensary obtain my Health Summary? Yes, we can also request your Health Summary on your behalf from your General Practitioner, please click the checkbox at the bottom of the form to grant MiDispensary to request this on your behalf.

For any questions, please contact us at info@midispensary.com.au or 1300MiTIME (1300 648 463).

New Patient Form

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, DVA & Concessions

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

If you do not have a Medicare Card, please input No for the above sections.

Individual Healthcare Identifier (IHI) Number If you do not hold a Medicare card, please input your Individual Healthcare Identifier Number also know as IHI Number.

If you do not know your IHI number please visit – How to get an Individual Healthcare Identifier via. Services Australia.

DVA NumberIf you are a DVA card holder please input your card number.

DVA Card Type

DVA ExpiryYYYY-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

Referring Practitioner Details

Practitioner Name *Please include the name of your current General Practitioner, and the clinic they are located at. Please note, we require specific clinic details of your General Practitioner to request your Health Summary.

Medicinal Cannabis Questionnaire

Are you aware you will need to obtain a Health Summary from your local General Practitioner? *

YesNo

You will need to provide your Health Summary to MiDispensary prior to your Initial Consultation. You can e-mail this to info@midispensary.com.au. If you wish to provide supportive documentation in relation to your chronic condition, you can attach it along with your Health Summary.

Are you aware that if you’re eligible and if you’re prescribed Medicinal Cannabis, you cannot legally drive or operate heavy machinery? *

YesNo

Find out more information about Medicinal Cannabis and Driving Laws on the Alcohol and Drug Foundation website adf.org.au.

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

YesNo

Are you aware costs of Medicinal Cannabis medication are approximately $100 – $350 per month and this cost is not covered by the Pharmaceutical Benefits Scheme (PBS)? *

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.

Are you aware that if the Medicinal Cannabis medication does not help with your condition there is no refund? *

YesNo

Are you aware a trial is generally 4 – 6 weeks to see the full benefits from Medicinal Cannabis? *

YesNo

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

YesNo

Are you aware that Medicinal Cannabis Flower is authorized for inhalation via. vaporization only? *

YesNo

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 any symptoms, 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.

Have you self-medicated with cannabis previously, or are you currently self-medicating with cannabis? *

YesNo

Do you understand and acknowledge that the long-term side effects of Medicinal Cannabis are unknown? *

YesNo

Do you understand that medicinal cannabis is not registered in Australia by the Therapeutic Goods Administration (TGA) of the Australian Department of Health and Ageing. Therefore, arrangements to access/import these medicines need to be made through a Special Access Scheme or Authorized Prescriber Scheme? *

YesNo

Do you understand that the Australian Government’s Therapeutic Goods Administration (TGA) doesn’t guarantee quality, safety and efficacy of Medicinal Cannabis? *

YesNo

Do you understand that the cost of Medicinal Cannabis is solely your responsibility and MiDispensary is not responsible for how much this cost may be? *

YesNo

Do you understand that it is an illegal offence to drive in Australia with any level of Tetrahydrocannabinol (THC) in your blood or saliva and if you drive with THC in your blood or saliva, you are breaking the law? *

YesNo

A legally issued prescription is not protection against these laws and MiDispensary is not and will not be responsible if you’re caught driving with THC in your blood or saliva.

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 to regular follow up consultations as indicated by MiDispensary and/or my Doctor. *

YesNo

If you are having a Telehealth appointment, please note that Telehealth allows you to consult a Health Care Provider by phone or a video call.

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

I understand that MiDispensary is not an Emergency Service and if immediate treatment is required, I should contact the nearest Emergency Department or call 000. *

YesNo

I agree to notifying my prescribing Doctor of any changes in my other medications. *

YesNo

I declare that all answers in this Medicinal Cannabis Patient Intake & Consent Form are true and correct to the best of my knowledge and belief. *

YesNo

I am aware the cost of my Initial Consultation with MiDispensary is $120.00 + 2.2% processing fee, and that a Follow Up Consultation is $65.00 + 2.2% processing fee and I acknowledge this will not be rebated by Medicare. *

YesNo

Health Summary Form

Health Summary Upload

Browse

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 –

Overview of patients medical history.
Outline of patients medication, including dosage and strength.
Any comments or concerns of treating Doctor regarding the patients health.

Recipient: I authorize my health care information to be released to Mi Dispensary at 260 Oxford Street Bondi Junction, NSW, 2022, Australia, to be sent via. e-mail to info@midispensary.com.au.

Purpose: I authorise the release of my health records for consideration of treatment with medicinal cannabis.

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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Please note that 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).

Our team at MiDispensary is committed to promoting a safe and secure environment for our staff so that the highest standard of service can be made available to our patients. As such, any instances of unacceptable behaviour from patients which may cause harm or fear of harm to any person in our organisation or themselves will result in a Letter of Dismissal to the patient from MiDispensary. By completing this form, you agree to these terms.