PRE-ELIGIBILITY TOOL

At Trava Health Clinic and Dispensary, we are committed to providing the best possible care to our patients.

Please take our simple 3 question Pre-Eligibility Tool, to help us determine whether medicinal cannabis may be suitable for you and your conditions.

Please Note:

Trava Health Clinic and Dispensary does not promote the exclusive use of medical plant-based alternatives. All information provided is to be used for informational purposes only and should not be taken to constitute medical advice, or an endorsement or a recommendation of any specific product or treatment. The results of the test does not gaurentee your elibility for the use and supply of medical plant-based alternatives (i.e. medicinal cannabis, such as oils, tinctures, extracts (e.g., CBD oil) raw and/or dried) to you, as such a determiation is regulated by State and Territory legislation, and any person who is interested in using such treatments should consult their healthcare practitioner, who will assess the person’s medical condition and suitability of treatment.

PRE-ELIGIBILITY TOOL - QUESTION 1

1. Do you suffer from any of the conditions listed below? *

YesNo

Please specify:

PRE-ELIGIBILITY TOOL - QUESTION 2

Were you diagnosed with your condition more than 6 months ago? *

YesNo

PRE-ELIGIBILITY TOOL - QUESTION 3

Have your past medical treatments or prescribed medications been unsuccessful in treating your conditions? *

YesNo

Thank you for submitting your answers.

Unfortunately, the information you have provided is not enough to determine your eligibility. To discuss your eligibility further, please contact us at 1300 371 317 or by email: admin@travahealth.com.au

CONTACT US

You successfully passed the eligibility check!

Please continue filling in the New Patient Registration form. If you require any assistance or queries, please contact us at 1300 371 317 or by email: admin@travahealth.com.au

Medical Confidentiality covers any information provided by you.

CONTINUE

NEW PATIENT REGISTRATION FORM

PATIENT DETAILS

Other:

First Name *

Last Name *

Preferred Name

D.O.B. *

Do you identify as Aboriginal or Torres Strait Islander? *

AboriginalTorres Strait IslanderNone of the AbovePrefer Not to Say

PATIENT CONTACT DETAILS

Phone Number *

Email *

Residential Address:

Address: *

Suburb: *

State: *

Postcode: *

EMERGENCY CONTACT

Emergency Contact's Full Name *

Emergency Contact's Phone Number (include Area Code as two digits if applicable) *

Emergency Contact's Relationship to You *

MEDICARE CARD NUMBER (Required for E-Prescriptions)*

Medicare Card No. *Please include all 10 Numbers - #### ##### #

Reference Number: *This number (single digit) can be found in front of your Full Name on your Medicare Card.

Expiry Date: *

PENSION / HCC / DVA CARD

Do you have an Aged Pension or Concession Card? *

YesNo

Aged Pension or Concession Card No.:

Aged Care Pension or Concession Card Expiry:

Do you have a DVA card? *

YesNo

DVA Card No.

DVA Card Expiry:

Do you have a Health Care Card?: *

YesNo

Health Care Card No.

Expiry

PRIVATE HEALTH INSURANCE

Do you have Private Health Insurance? *

YesNo

Name of Insurance Provider

Membership Number

MEDICAL HISTORY

Please provide us with a brief description of your medical history.

Other (from above):

Would you like to provide your doctor, prior to your consultation, with any additional information as to your illnesses that you haven't already told us? *

YesNo

Please provide the details and information in the box below:

Please note, that we might require further information from your GP or treating psychiatrist to determine if medical cannabis treatment suits you. If you already have a health summary or referral letter from the treating practitioner, please email it to admin@travahealth.com.au before your appointment

Are you pregnant, planning to becoming pregnant or breast feeding? *

YesNo

Please Note: General cautions by TGA: Medicinal cannabis are not appropriate for women who are pregnant, planning to become pregnant or breastfeeding.

Do you suffer from previous psychosis, anxiety mood or anxiety disorder (personal, not family)? *

YesNo

Please Note: General cautions by TGA: Medicinal cannabis is not appropriate for people with an active or previous psychotic or active mood or anxiety disorder.

Have you ever had a psychotic episode or been diagnosed with schizophrenia? Have you ever had a manic episode, concurrent active mood, or been diagnosed with bipolar disorder? *

YesNo

Please Note: General cautions by TGA: Medicinal cannabis is not appropriate for people with an active or previous history of schizophrenia, mood disorders, or bipolar?

Do you have a history of liver disease or dysfunction? *

YesNo

Do you suffer from unstable cardiovascular disease? *

YesNo

MEDICATION & ALLERGIES

Are you currently taking any prescribed medication? *

YesNo

Name of Medication

What treatment was this Medication for?

Did you experience any side effects? If so, please describe.

Do you suffer from any allergies? *

YesNo

Allergic to:

Please describe the type of allergy (e.g anaphylaxis, rash etc.)

PAST OR CURRENT USE OF CANNABIS

Information about your previous or current experience with cannabis is vital in assessing and determining the best treatment for you with Medical Cannabis.

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

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

Are you currently a patient of another medical cannabis clinic?

YesNo

Name of Clinic

Attach any relevant documents that you would like your practitioner to use, (i.e. otology result / images / specialist document / other).

Browse

HOW DID YOU HEAR ABOUT US?

How did you find out about Trava Health? *

How did you hear about us (OTHER):

CONSENT

Disclaimer:

Trava Health Clinic and Dispensary does not promote the exclusive use of medical plant-based alternatives. The use and supply of medical plant-based alternatives (i.e. medicinal cannabis, such as oils, tinctures, extracts (e.g., CBD oil) raw and/or dried) is regulated by State and Territory legislation. Any person who is interested in using such treatments should consult their healthcare practitioner, who will assess the person’s medical condition and suitability of treatment, before prescribing. Trava Health Clinic and Dispensary accepts no responsibility or liability whatsoever for any person’s reliance on the information or affiliates via links on our website or within our forms. Ensure you aware and adhere to any laws relating to the operation of any: vehicle; boat; aircraft; machinery; or other regarding use of THC or MC and blood, serum, saliva, or other levels.

I acknowledge that the long term side effects of medicinal cannabis are unknown. *

I understand that the cost of medicinal cannabis is solely my responsibility. *

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 my personal information with both the TGA and your state Health Department and/or authorities.

*

I acknowledge that the Australian government’s Therapeutic Goods Administration (TGA) doesn’t guarantee quality, safety and efficacy of medicinal cannabis and no guarantee that medicinal cannabis treatment will improve my condition.

*

I agree to follow my doctor’s recommendation concerning dosing and report any adverse effects of medicinal cannabis, including, but not limited to, sedation; lethargy; fatigue; dry mouth;nausea; vomiting; diarrhoea; drowsiness; dizziness; disorientation; agitation; balance problems; changes in memory, paranoid delusions, or hallucinations. I understand that unknown risks and late side effects are possible. I acknowledge that the long-term side effects of medicinal cannabis are unknown.I know medicinal cannabis might interact with my other medications, and doses may need to be adjusted accordingly.

*

I acknowldege that I understand that both my Trava Health doctor and the TGA need to sign off on approval for my continued access to medicinal cannabis. *

I agree to be available for my appointment and to give at least 48 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.

*

I agree to regular follow-up consultations in person or telehealth as indicated by my Medicinal Cannabis Practitioner.

*

I confirm that any and all information provided by me regarding my medical history, medication summary and personal details is accurate and relevant. *

DISPENSARY & DELIVERY

I consent that choosing Trava Health Clinic and Dispensary's chosen courier service to deliver my future medications. I understand that if I decide to engage any other courier service or pick up the medicine, I have to inform Trava Health Clinic and Dispensary about my new arrangements. I know that at the point of processing an order, subject to my eligibility and doctor's consultation, deliveries may be subject to delays or loss during transportation, that it is my responsibility to ensure that the delivery address provided is accurate and that someone is available to receive the delivery or if I am not available to receive the delivery, the medication may be returned to the clinic or may be subject to additional fees for redelivery. I understand that by consenting to use Trava Health Clinic and Dispensary's chosen courier service and I release Trava Health Clinic and Dispensary from any liability or responsibility for any lost or stolen parcels during the transportation. *

I consent to Trava Health Clinic and Dispesary to store and use the payment method I provide for all future appointments and delivery charges and understand if this payment method changes, requires updating, or an alternative option is my preference, it is my responsibility to update Trava Health Clinic and Dispensary. *

Please provide your chosen Delivery Address, even if the same as your Residential Address:

Delivery Address: *

Suburb (Delivery Address): *

State (Delivery Address): *

Postcode (Delivery Address): *

SIGNATURE

By signing I agree to receive automated appointment reminders and information from Trava Health via SMS, email or phone. I can opt out of these processes by emailing admin@travahealth.com.au *

I confirm that the above information I have provided is true, complete and accurate, filled in by me. *

I have read and agree to the Terms and Conditions published on Trava Health Clinic's website. *

Patient / Guardian Signature *

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Today's Date (DD/MM/YYYY) *

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