Trava Health Medicinal Cannabis Clinic

Quick Eligibility Test

ELIGIBILITY CHECK (3 questions only)

Question 1

Other (please specify):

Question 2

Have established medications/treatments been unsuccessful in treating your medical conditions, or have you experienced adverse side effects? *

YesNo

Question 3

Has your condition lasted for more than three months? *

YesNo

It looks like you have passed the Eligibility Check!

Please continue filling in the Patient Registration Form.

If you have any questions or require additional help while completing the registration form,

please contact us on 1300 371 317

between 9am - 5pm (ADST) Monday - Friday

To complete this form, you will need:

Medicare Card, Pensioner/Health Card (if valid).

I agree for a member of Trava Health Clinic to contact me in regards to my medicinal cannabis enquiry, using one of the contact details below.

PATIENT DETAILS

Gender *

FemaleMaleOther

Full Name (Given Name, Second Name, Last Name) *First Name, Second Name and Surname as registered on Medicare Card

Preferred Name

Date of Birth *DD/MM/YYYY

Phone Number *

Email *

FULL ADDRESS inclusive of post code *Number of App/Unit, Number of Building, Street Name, Suburb Name, State, Post code

Do you identify as Aboriginal or Torres Strait Islander? *

AboriginalTorres Strait IslanderNone of the AbovePrefer Not to Say

MEDICARE CARD NUMBER (for E-Prescribing)

Medicare Card No. *10 digit number

Reference number: *Number in front of your full name on Medicare card

Valid to/ Expiry Date *MM/YYYY

Pensioner/ Health CarePlease enter valid Card number and Expire date

Health fund name (if applicable)

Veteran Affairs number (if applicable)Please enter valid Card number and Expire date

CANNABIS STATUS

Information about your previous or current experience with cannabis is essential in assessing the best suitable treatment for you. Any information provided here or directly to your doctor is covered by medical confidentiality.

Which of the following best describes your experience with cannabis? *

I am currently using /have been using cannabis to treat symptoms of a medical condition (including self-medication)I have never used cannabis

Please provide details of any current use (i.e. how much, how often, whether you smoke, vaporise, take edibles etc.) *

MEDICAL HISTORY AND MEDICATIONS LIST

Have you ever had a previous history of psychosis or concurrent active mood disorder or been diagnosed with schizophrenia or bipolar disorder? *

YesNo

Recommendation from the Therapeutic Goods Administration (TGA) that THC is inappropriate for patients with a previous history of psychosis or concurrent active mood disorder.

For patients with a history of psychosis or mania, we might require further information to evaluate whether medical cannabis is suitable as a treatment option. If you already have a health summary or supporting referral letter, please upload them at the end of this form or email them to admin@travahealth.com.au before your appointment.

Are you pregnant or planning to become pregnant or currently breast-brestfeeding? *

YesNo

The Therapeutic Goods Administration (TGA) recommends that THC is inappropriate for expectant mothers, females who are planning a pregnancy or those breastfeeding.

Are you taking any medications? *

YesNo

List Medications you're currently taking *

Do you have allergies, side effects or tolerance to medications? *

YesNo

List all the allergies you had in past and adverse reaction/allergies to Medications :

Do you have a history of heart disease or unstable cardiovascular disease? *

YesNo

Please provide details if answered "Yes"

Do you have a history of any other disease or dysfunction? *

YesNo

Please provide any additional information ,details, including any investigation, treatment or monitoring undertaken that you would like to share with your Medicinal Cannabis Practitioner

Please, upload any medication summary, health summary, files or documents, or referral letters that you would like to present to your Medicinal Cannabis Practitioner.

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Welcome to Trava Health Clinic.

Thank you for completing Patient Registration Form.

To the accelerate appointment booking process we encourage our patients

to contact us by calling 1300 371 317 between 9am-5pm (ADST) Monday-Friday

or emailing to admin@travahealth.com.au

or alternatively our friendly staff member will contact you within 24-48 hours

to arrange the INITIAL CONSULTATION appointment.

How did you find out about Trava Health? *

CONSENT

I acknowledge that medicinal cannabis is not registered in Australia by the Australian Department of Health and Ageing Therapeutic Goods Administration (TGA). Therefore, arrangements to access these medicines are applied through a Special Access Scheme or Authorised Prescriber scheme, which may involve sharing my personal information with both TGA and the state Health Department. In addition, I understand that both TGA and Trava Health Clinic Practitioner need to approve my access to medicinal cannabis treatment. *

I understand that driving or operating machinery in Australia with any level of tetrahydrocannabinol (THC) in my blood/urine or saliva is an offence. Therefore, I am breaking the law if I drive a vehicle or operate machinery. A legally issued prescription is not protected me against these laws. *

I consent that Trava Health doctors contact any health departments/hospitals/pathologies or other treating practitioners to obtain further clinical information if required. *

I acknowledge that TGA does not guarantee the quality, safety and efficacy of medicinal cannabis and long termside effects of medicinal cannabis are unknown.I agree that the cost of medicinal cannabis is solely my responsibility. *

I agree to regular follow-up consultations (maximum 12 weeks interval between each consultation) as indicated by my Medicinal Cannabis Practitioner. In addition, I agree to be available for my appointments and to give at least cancellation notice a minimum of 48 hours prior. If I miss my appointment without notifications, my rebooking of the appointment might attract additional fees by Trava Health Clinic. *

SIGNATURE

I confirm that I filled this form by myself, and the information provided is true, complete and accurate. *

Patient/ Guardian Signature *

Clear

Today's Date *DD/MM/YYYY

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