Telehealth Consultation Telehealth Consultation Booking a consultation with one of our specialists is the first step. Complete the form and proceed to next screen to upload proof of identification and medical history reports. Patient Name * Patient Name First First Last Last Email * Contact Number * D.O.B * Patient Gender * MaleFemaleOther Address * Address Address Address City City State State PostCode PostCode Medicare Number * Reference Number * Expiry Month/Year * What medications are you currently on? * Other illnesses: * Do you see a regular GP/Specialist? * Are you on any prescribed drugs of dependence such as methadone? Subuxone? etc * List any side effects and any reason for stopping or N/A Have you been prescribed medicinal cannabis previously? * Yes No Do you currently experience, or have been diagnosed with the following: * Psychosis Bipolar disorder Mood disorder Severe anxiety Cardio-respiratory disease Drug dependence or substance abuse N/A OtherOther Do you see a psychiatrist? * Yes No Have you had any recent surgeries? * Yes No Are you pregnant, breastfeeding or considering breastfeeding? * Yes No Do you have a copy of your most recent medical summary? * Yes No Please request this from your GP and attach recent copy on next screen Are you open to discussing lifestyle and diet changes to assist in ongoing management? * Yes No Confirmation * I understand that the above details will be used as for medical documentation. I confirm that all the details provided are true and correct to the best of my knowledge. If you are human, leave this field blank. Next Start again