ECS Ref - Dr Bos

Patient Registration Form

ECS

PATIENT DETAILS

First Name

Last Name

Date of Birth

Mobile Phone

Email

Address

City / Suburb

Postcode

State

English is a Second Language

YesNo

Gender

MaleFemale

Ethnicity

ATSI

AboriginalTorres Strait IslanderNone of the Above

EMERGENCY CONTACT DETAILS

Name

Address

Postcode

City / Suburb

State

Mobile Phone

Email

REFERRING DOCTOR TO US

Referring Doctor’s Name

Address

Family Doctor/ Regular General Practitioner Name (if different to referring doctor)

Address

MEDICARE / PRIVATE HEALTH

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

YesNo

If you use Alias please write the Alias name & surname

Medicare First & Last Name

Medicare Card No.

Cardholder Position

Expiry

Do you have private Medical insurance

YesNo

Provider

Membership No.

Expiry

PENSION / HCC/DVA Card

Card Type

HCCPension

Do you have an aged pension card, healthcare card or a DVA card

YesNo

Card No.

Expiry(mm/yyyy)

DVA No.

MEDICAL CANNABIS QUESTIONAIRE

Have you tried conventional medications with poor symptom control and/or intolerable side effects? *

YesNoUnsure

Do you have a Chronic Condition? *

Yes NoUnsure

A chronic condition (also known as chronic disease or chronic illness) is a health condition or disease that is persistent or otherwise long- lasting in its effects or a disease that comes with time. The term chronic is often applied when the course of the disease lasts for more than three months.

Do you have any allergies and/or adverse reactions? If yes, please list them *

List any symptoms you experience related to your health conditions *

List all of your current medications and treatments for your current condition(s) *

Do you have an unstable heart condition – e.g. unstable angina? *

Yes NoUnsure

Are you pregnant or breastfeeding? *

YesNo

Have you been diagnosed with Schizophrenia, or have a family history of Psychotic episodes personally or within your family? *

Yes No

If you have ticked yes to this question, additional documentation may be required from a suitable healthcare practitioner.

I am aware and understand the risks and complications associated with Medicinal Cannabis treatment, and I agree to follow my doctor’s recommendations with regards to dosing and report any adverse effects of Medicinal Cannabis including – changes in the level of sedation, lethargy, fatigue, dry mouth, nausea, vomiting, diarrhoea, drowsiness, dizziness, disorientation, agitation, balance problems, changes in memory, paranoid delusions or hallucinations *

YesNo

I agree that I will not use any other forms of cannabis other than what is prescribed by my doctor – including any illicit forms of cannabis (marijuana) *

YesNo

Health Summary Consent Authorization for Use/Disclosure of Information,

I consent to sharing my health care records in the form of a Health Summary including the following details, if applicable – medical history, current and previous medications, and any comments or concerns regarding patients health.
I authorize my health care information to be released to Bosman Clinic to be sent via. e-mail to drmanusbosman@gmail.com and the release of the above information pertaining to my personal medical records. *

Where you referred by ECS? *

YesNo

SIGNATURE

I declare all answers provided herein are true and accurate to the best of my knowledge and belief. *

Patient/ Guardian Signature *

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Today's Date

Important: Consultation with a Doctor does NOT guarantee prescriptions for medicinal cannabis medications. As per the Therapeutic Administration Guidelines, this treatment option isa second-line treatment modality where all othertreatments have failed. Provision of prescriptions is at your treating Doctor's discretion.

Updated New Patient Form

Important: Completion of this form does not reflect anyappointment bookings. Once your form is received by our team, you will be redirected to an appointment scheduling and payment processing page. Should you have any questions, please contact us directly at drmanusbosman@gmail.com.

Bosman Clinic is not an Emergency Service and if immediate treatment is required you should contact the nearest Emergency Department orcall 000.

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