Referrals Form

 

Please provide information about your patient and a member of the team will be in touch to arrange a consultation. 

Alternatively, you can send us an electronic referral using our EDI: cannacli 

 

Clinician Information

Clinician Name(Required)

Patient Information

Patient's Name(Required)
Date of Birth(Required)
Is the Patient Pregnant or Breastfeeding?(Required)
Does the Patient have a history of substance abuse or addiction?(Required)
Does the Patient have a history of psychosis or schizophrenia?(Required)