Doctor Referral Form Name First Last Email(Required) Date of Birth(Required) MM slash DD slash YYYY Gender Is the patient of Aboriginal and/or Torres Strait islander origin? Phone number(Required)Patient Address(Required) Medicare Card Number(Required) Concession Card DVA Number Conditions - Please select the condition/s that apply*(Required) ADHD Anxiety ASD Cancer-related Pain Chemotherapy-Induced Anorexia Chemotherapy-Induced Nausea and Vomiting Chronic Non-cancer Pain Depression Epilepsy Insomnia Movement Disorders Multiple Sclerosis Other PTSD Current or Trialled Medications(Required) Antipsychotics Benzodiazepines Opiods Other medication SSRI TNF Blocker Is the patient currently accessing medicinal cannabis through another provider?(Required) Yes No Referring Doctor Name(Required) Referring Doctor Provider Number(Required) Practice Details(Required) How would you like to receive correspondence?*(Required) Email Fax