Medicine Request Form

Medicine Request Form

"*" indicates required fields

Name*
Do you have a current Community Services Card (CSC)?*
If you ticked Yes, please upload an image of your card, or provide your CSC number and expiry date below.
Max. file size: 1,000 MB.
I'm within my follow up period & not due to have a consultation with my doctor*
If not, you will require a follow-up consultation with your doctor. Click Here To Book a Follow-Up
Please note you can only select one medication at a time.
Have you previously been prescribed the medicine you are requesting?*
What is the reason for your request?*
Are you experiencing any side effects on your current medicinal cannabis regime?*
Please enter a number from 1 to 10.
1 being ineffective, and 10 being very effective

Declaration & Consent

1. Due to the legal restrictions on Medicinal Cannabis, changes to prescribed medication requires review and oversight from our clinical team. 2. As your request falls outside of your scheduled consultation, it will be forwarded to our prescribing doctor to review. 3. You will need to book a follow-up consultation if you want to: - Change your medication to a higher THC percentage. - Switch the type of medication (for example, from THC oil to whole flower). 4. The prescription is subject to the doctor's discretion and may involve the cancellation of previous prescriptions with outstanding repeats.*
Client's Declaration*
To the best of my knowledge, the information that I have supplied is complete and correct.