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

HOW DID YOU HEAR ABOUT US?

How did you find out about Trava Health? *

How did you hear about us (OTHER):

CONTRADICTIONS FOR MEDICINAL CANNABIS TREATMENT (THC)

Prior to seeking consultation with one of our doctors please note:

History of hypersensitivity to any cannabinoid (THC , CBD),
Severe unstable cardio-pulmonary disease (angina, peripheral vascular disease, arrhythmias, cerebrovascular disease) In those who smoke cannabis, there is a four fold risk of myocardial infarction in those patients with unstable ischaemic heart disease,
Personal or family history of schizophrenia or other psychotic illness,
Pregnancy / breastfeeding,
Severe liver or renal disease,
Persons under 18 years of age.

CONSENT

Disclaimer:

Trava Health Clinic and Dispensary does not promote the exclusive use of medical plant-derived alternatives. The use and supply of medical plant-derived 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 prescriber and relevant government authorities 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. *

I acknowledge It is an offence for a person to drive with any amount of THC in their system, including any amount of THC from medicinal cannabis. *

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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