New Patient Registration Form Email(Required) Name(Required) First Last Date of birth(Required) MM slash DD slash YYYY Gender Phone number(Required)Street address(Required) City(Required) State/Region(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 Do you consume?(Required) Alcohol Tobacco Cannabis Other illicit drugs Are you currently accessing medicinal cannabis through another provider?*(Required) Yes No Do you have a health summary or referral?(Required) Health Summary Referral No, I will need to get one Who is your regular or diagnosing practitioner?(Required) Regular Treating Practitioner Address Contact Number?Email address? Informed Consent to Treatment(Required)I acknowledge that: Medical Cannabis is currently considered a trial or investigational medication in Australia. In many cases, there is limited clinical based data from which to draw specific recommendations for treatment (for more information visit: https://www.tga.gov.au/medicinal-cannabis-guidance-documents). Medicinal cannabis is not a registered medication and therefor it is not available on the PBS. In order to commence medicinal cannabis treatment in Australia I understand that the prescribing doctor must seek approval from the Therapeutic Goods Administration (TGA) of the Australian Department of Health and Ageing. I agree to pay all treatment fees and attend mandatory appointments. Medicinal cannabis may interact with my current medications and cause adverse side effects. I understand I must inform my doctor should my health or medications change. I understand that I should not consume alcohol and medicinal cannabis together. Possible side-effects of a medical cannabis treatment may include and are not limited to: Confusion, Disorientation, Dizziness, Drowsiness, Sleepiness, Sedation, Balance problems, Coordination, Memory problems, Dry Mouth, Fatigue, Increased appetite, Cognitive impairment, Light-headedness, Euphoria. Many of the side effects are dose dependent. Should I experience one or more of these on-going I understand I must let my prescribing doctor know immediately. The medication prescribed is for my personal use only. I understand that I must keep all medication in it's original packaging. I understand that driving whilst taking medication containing THC is currently illegal in Australia. I agreeAre you of Aboriginal and/or Torres Strait islander origin?