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Section 1 of 3
We’re going to ask a few general questions and questions
regarding your consent in the use of alternative medicine.
Are you a patient?*
Do you reside in Australia?*
Are you 18 years or older?*
Do you confirm that you are NOT currently
pregnant or breastfeeding?*
Do you acknowledge that using Medical cannabis comes with potention side-effects and adverse events?
Do you agree to report all side effects and adverse events to LeafMedicine ASAP?
Do you agree to stop medication immediately and seek urgent medical advise if any major or concerning side effects or adverse events occur?
Do you confirm that you do NOT have any of the following medical conditions:
(Abnormal heart rhythm, cardiopulmonary or heart disease, liver disease, or a known or suspected
history of any psychotic disorders in yourself or your family - i.e schizophrenia, bipolar, etc.)
Do you confirm that you do NOT have any history of drug
dependence/abuse of following:
(Opiods, MDMA, Amphetamines, other illicit substances))
Do you acknowledge that any medication prescibed via LeafMedicine is for yourself only?
Do you acknowledge that there are driving restrictions when consuming products that contain Tetrahydrocannabinol (THC)?
Section 2 of 3
In the next few questions we’ll ask you for some general
info about you to help us discover your eligibility
Select the reason(s) you are seeking assistance today with LeafMedicine for your presenting medical problem(s):
Date of Birth *
Gender: Please let us know how you identify*
Weight *
Height *
Mobile Number *
Section 3 of 3
Just a few more questions on your medical history
to determine your eligibility, then we’re done
What is your presenting medical problem(s)?
Describe your problem in more detail*
(disclaimer: it is important to give a complete and accurate description of your presenting medical problem. Failure to do so may cause delays or impact your eligibility for treatment)
Please provide details on any medical conditions known within your family e.g heart disease, diabetes (optional)
Are you currently taking medication for your presenting complaint or any medication in general?*
Please list all medications or supplements/vitamins you are current taking:
(disclaimer: it is important to give a complete and accurate description of your presenting medical problem. Failure to do so may cause delays or impact your eligibility for treatment)
Do you have any allergies or sensitivites?*
Please list any allergies or sensitivites here*
Please select any alternative therapies you have tried
What is your alcohol intake (glasses per week)*
What has been your experience with Cannabis?*
Declaration*
- I verify that I have answered all questions honestly, accurately, and to the best of my understanding.
- I hereby give consent for Leaf Medicine to review my health record, communicate with my prescribed doctor, and employ my information.
- I also give consent for Leaf Medicine and associated healthcare practitioners to assist in my treatment and contact me for reminders and assistance.
- If deemed necessary, I am willing to facilitate the transfer of my medical records between my primary care providers and the clinical team at Leaf Medicine
- Medicinal cannabis is not a guaranteed cure, and the effectiveness of the treatment may vary from patient to patient
- The scientific evidence of its effectiveness is limited it may have some side effects, which will be discussed by the precriber at the time of consultation.
- Using cannabis-based products in combination with alcohol is not recommended.
- I will be closely monitored by my medical practitioner during the course of the treatment, and any changes to the treatment plan will be discussed with me
- The use of medicinal cannabis may have legal restrictions and requirements, and I must comply with all applicable laws and regulations.
- I have the right to withdraw my consent for medicinal cannabis treatment at any point, provided I inform my healthcare provider in writing.
- I must take the treatment strictly as recommended and only alter the dose in discussion with my doctor
- I shall report any beneficial effects and any side effects to my doctor
- Driving or handling machinery while under treatment with THC-containing medicinal cannabis products is prohibited
- I shall always keep the prescribed medicinal cannabis product in its original pharmacy container or bottle and ensure that the pharmacy labels remain undamaged.
- sharing medical cannabis with others is a crime and may result in criminal liability
I understand & acknowledge the above
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Followup consultation
$59
- In depth health review & personalised treatment plan
- Compassionate care
- Online script and express delivery to your door
- No referral required
