NICOTINE VAPING REGISTRATION

PATIENT DETAILS

First Name *

Last Name *

Preferred Name

Date, months, Year of Birth *

Mobile Phone *

Email *

Address *

City / Suburb *

Postcode *

State *

Gender *

MaleFemaleOther

ATSI *

AboriginalTorres Strait IslanderNone of the Above

MEDICARE CARD NUMBER

Do you use a different name in your medicare card? *

YesNo

If you use Alias please write the Alias name & surname

Medicare Card No. *Its 10 digit number

Medicare Reference Number *Patient reference number recoded in front of patient name on Medicare Card

Valid to/ Expiry Date *Months/Year

SMOKING HISTORY

Which best describes you? *

Current SmokerEx-SmokerNever Smoked

How many cigarettes do you smoke on an average a day? *

Less than 55-1011-2020 +

What method(s) have you previously tried to assist you in quitting? (Tick all that apply) *

MEDICAL HISTORY

Please list below any significant medical illnesses, such as diabetes, cancer, asthma, COPD/emphysema or psychiatric disorders. *

Have you had a stroke, heart attack, irregular heartbeat, uncontrolled hypertension or angina in the past month? *

YESNO

Have you ever consumed medicinal and/or 'street' cannabis? *

Yes. I am a recreational user.Yes. I self-medicate.No, but I would like to know more about medicinal cannabis treatments.No.

SAFETY INFORMATION AND CONSENT

Complete abstinence from smoking and vaping is the safest option for your health. Nicotine is addictive, and the long-term effects of vaping are unknown. Currently no vaping products containing nicotine have been approved by the TGA, and the safety of these products has not yet been thoroughly assessed. Trava Health encourages our patients to exercise relevant caution and only purchase these products from an authorised prescriber and/or retailer. Trava Health, nor its associated staff or doctors do not guarantee the safety of any vaping product. In order to minimise risk, only short-term use of nicotine vaping products (e-cigarettes) is recommended.

SIGNATURE

I confirm that above information I have provided is true, complete and accurate. *

By signing I agree to receive automated appointment reminders and information from Trava Health Clinic via correspondance, SMS, email or phone. If I wish to opt out of these processes I am aware of process to send and email to admin@travahealth.com.au to opt out. *

Patient/ Guardian Signature *

Draw signature|Type signatureClear

Today's Date *

Save and Complete Later