Form

To be eligible to book an appointment, we require the following form to be submitted.

If you do not have time to complete this now, we have sent this to your email to complete at your earliest convenience.

First Name*

Last Name*

Date of birth*

State/Region*

Postal code*

Primary Chronic Health Condition(s)*

What are the main chronic (lasting more than 3 months) health conditions you aim to consult about? Please list no more than 2-3.

Investigations Undertaken

● Please list all investigations that were carried out by your healthcare provider(s) for the conditions listed above. Investigations may include: x-ray, ultrasound, blood tests. If none, please write NA.

Medications taken for Chronic Conditions

● Please list all medications (prescribed/ceased prescribed, past and present, over the counter) that you have taken for your chronic condition(s).
● Explain which ones helped with your condition(s) and which ones didn't help. If none, Please write NA.

History of other Conditions

Do you have any personal history of unstable heart disease (e.g, past heart attack) or recent hospitalization?

Family or Personal History of Schizophrenia/Psychosis/bipolar/Suicidal Attempts/Ideation?*

● Do you or does anyone in your family have a history of schizophrenia/psychosis/bipolar?

Yes

Do you have any allergies?*

Yes

Do you have any experience with Cannabis?

● Your experience with cannabis (if any) helps your doctor to understand and formulate a treatment plan that best suits you.

Current Prescription and Clinic Information

● If you currently have a prescription, please tell us which prescription you have (what works and doesn’t) and clinic/doctor you are currently seeing?
● If not already prescribed, type NA. *If you become a patient of Telegreen you understand you cannot have more than 2 medical cannabis clinics managing your medical needs simultaneously* (TGA regulatory compliance)

Do you suffer from any illicit substance dependence or is on a opioid treatment program (OTP)?*

Yes

Females only

● If prescribed natural therapy, do you acknowledge to take contraception or other reasonable methods to prevent pregnancy and/or cease treatment if pregnant or Breastfeeding

Yes

Consent for Unapproved Medicines (Medicinal Cannabis)

● “Medicinal cannabis is an unapproved medicine. By agreeing to TelegreenMedical’s Consent for Unapproved Medicines before this consultation, you provide consent to be prescribed an unapproved medicine (if deemed suitable) and acknowledge the associated risks, restrictions, and possible complications outlined below.
● You will be asked this again during your initial consultation to confirm that you understand this by saying ‘Yes.’ Your verbal agreement will be documented by the HCP as secondary confirmation of your consent to be prescribed an unapproved medicine.”
● Benefits, Risks, Restrictions, and Possible Complications of Medicinal Cannabis
● By signing this document, I acknowledge that I understand and agree to the following:
● I understand that the quality, safety, and efficacy of medicinal cannabis have not been assessed by the Australian government’s Therapeutic Goods Administration (TGA). As a result, access to medicinal cannabis is only available through a Special Access Scheme (SAS), Authorised Prescriber Scheme (AP), or Clinical Trial pathways under the TGA Goods Act 1989.
● I acknowledge that unapproved medicines, including medicinal cannabis, are generally considered experimental, with limited data to inform specific treatment recommendations. For more information, I can visit the TGA website: www.tga.gov.au/medicinalcannabisguidance-documents.
● I understand that the long-term side effects of medicinal cannabis are unknown, and I may experience negative or unwanted side effects.
● I agree to follow my doctor’s recommendations regarding dosing and report any adverse effects to my healthcare team, including but not limited to sedation, lethargy, fatigue, dry mouth, nausea, vomiting, diarrhea, drowsiness, dizziness, disorientation, agitation, balance problems, memory changes, paranoid delusions, or hallucinations.
● I understand that medicinal cannabis may interact with other medications I am taking, and adjustments to my treatment may be necessary.
● I agree to follow any recommendations for blood tests or additional investigations related to my medicinal cannabis treatment.
● I understand that alcohol, intoxicants, or recreational drugs may interact with medicinal cannabis treatment and affect my health.
● I waive and disclaim any rights to claim against TelegreenMedicals for any potential side effects, adverse effects, or unknown risks related to medicinal cannabis use.
● I understand that the cost of medicinal cannabis, if prescribed, is my responsibility and is not covered by government programs such as the Pharmaceutical Benefits Scheme (PBS).
● I acknowledge that driving or operating a motor vehicle, tram, train, or vessel with delta-9tetrahydrocannabinol (THC) in my system is illegal, and I am responsible for being aware of specific laws in my State or Territory. A prescription does not provide a defense for these offenses.
● I agree to refrain from driving or operating heavy machinery while using THC and understand that doing so may violate the law.
● I agree to keep a log of my doses and any changes in symptoms due to medicinal cannabis use.
● I agree to attend regular follow-up consultations, either in the clinic or over the phone, as directed by my healthcare provider.
● I understand that sharing, selling, lending, or giving away my medicinal cannabis is illegal, and I acknowledge that my healthcare provider or pharmacist may work with law enforcement or government authorities to investigate any alleged misuse.

I acknowledge that I have read and understood the consent stated above to the best of my knowledge.

Yes