Consultation Enquiry

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Required*

Consultation Enquiry

    1 Quick Eligibility Check
    Required*
    Do you suffer from any of those conditions below*
    Yes No

    2 Patient Details*
    Required*
    Please include all 10 Numbers
    ?
    The reference number (single digit) can be found in front of your Full Name on your Medicare Card.

    3 Medical History*
    Required*

    Please list the chronic illnesses you were diagnosed with or have had treatments for.

    This information is required to accurately assess your eligibility for medical cannabis. Please be as specific as possible and list all side affects you have experienced. If you have a file with this information, and/or you would prefer to include it as an attachment, please state “As Attached”, and attach your document with this form.
    ?
    If you need to add more medications, click on the add another row button
    Or
    Attach List of Medications Currently Being Taken
    No file chosen Upload your prescription or any other relevant file. Max. file size: 3 MB. Accepted files: .pdf .doc .docx.
    ?
    If you need to add more rows for allergy and reactions, click on add another row button

    4 Cannabis History
    Required*
    For patients with a history of psychosis or mania we often require further information from your GP or treating psychiatrist to evaluate whether medical cannabis is appropriate. If you already have a health summary and/or referral letter, please attach these in the previous step or email to info@medigreenaustralia.com.au
    Pregnancy and breastfeeding are contraindications (meaning you are not eligible) for treatment with Medical Cannabis.
    • I acknowledge that the long-term side effects of medicinal cannabis are unknown I acknowledge 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 these medicines need to be made through a Special Access Scheme or Authorised Prescriber scheme, which may involve sharing your personal information with both the TGA and your state Health Department.
    • I acknowledge that the Australian government’s Therapeutic Goods Administration (TGA) does not guarantee quality, safety and efficacy of medicinal cannabis.
    • I acknowledge that I understand that as medicinal cannabis is an unapproved medication, that my MediGreen doctor will have the authority to confirm my eligibility for medicinal cannabis.
    • I agree to be available for my appointment and to give at least 24 hours’ notice of cancellation. If I miss my appointment, then any entitlement to a rebooking or refund is entirely at the discretion of the clinic.

    By signing I agree to receive automated appointment reminders and information from MediGreen Clinic via SMS, email or phone. I can opt out of these processes by emailing info@medigreenaustralia.com.au

    I confirm that above information I have provided is true, complete and accurate.

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    SIMPLE STEPS

    Consultation Process

    1

    Consultation Enquiry

    Enquire for consultation. Start your journey to better health. It’s that simple

    2 Consultation Enquiry

    Order Your Prescription

    Order medical products at our pharmacy

    3

    Pickup or Delivery

    Flexible delivery options available for your convenience

    REPEATS MADE EASY

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    Prescription?

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