Initial Consultation - EverPeak Patient Medical Questionnaire MC

Name

First NameLast Name

Date of birth

Date

Phone Number

Please enter a valid phone number.Format: 0000-000-000.

Email

example@example.com

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Medicare Number (If you do not have one, please place 12345 in the box below)

Medicare - Check Digit (number next to your name) (If you do not have one, please enter 1 in the box below)

Medicare - Exp (e.g. 04/2030) (If you do not have one, please enter 1 in the box below)

If you do not have a Medicare card but have an Individual Healthcare Identifier (IHI) a unique number used to identify you in Australia’s healthcare system, please enter it below.

What are the main health condition(s) or symptoms for which you are seeking treatment? Please describe them in your own words, including how long you have experienced them.

Please describe the severity of your condition and how it affects your daily life, including your sleep, work, mood and ability to complete everyday activities.

What treatments have you previously tried, including medications, therapies or other approaches? Please include what worked, what did not work and any side effects you experienced.

Have you ever been diagnosed with or received treatment for any of the following conditions?

If you answered ‘Yes’ to any of the above, please provide further details.

Are you currently pregnant, breastfeeding or planning to become pregnant?

If you answered ‘Yes’ to the above question, please provide further details.

What medications or supplements are you currently taking? Please include the dosage, if known.

Do you have any current or previous medical conditions, mental health conditions or significant illnesses? Please include any relevant hospitalisations.

Have you previously used cannabis for medical or recreational purposes? If yes, please describe your experience, including the effects, benefits, side effects and frequency of use.

Are there any safety considerations we should be aware of? For example, pregnancy or breastfeeding, driving requirements, substance use or allergies.

What are your goals or expectations for medical cannabis treatment?

Please select the appointment date and time that suits you best. All appointments are displayed in Sydney local time (AEST/AEDT), so please keep any time difference in mind if you are booking from another state or territory.

Please select your preferred option for your telehealth appointment:

Appointment Booking: Payment is required at the time of booking to secure your appointment.

Initial Doctor Consultation

A comprehensive first appointment where the practitioner reviews your medical history, discusses your concerns, and assesses your suitability for treatment.

$120,00 AUD

Total

Debit or Credit Card
Credit Card Number	Security Code
Expiration Month	Expiration Year

PHARMACY NOMINATION AND CONSENT

If my treating practitioner determines that a prescription is clinically appropriate, I consent to EverPeak and my treating practitioner securely providing my prescription and the personal and health information reasonably necessary for dispensing and delivery to Cann Compounding, EverPeak’s nominated dispensing pharmacy.

I understand that:

• completing this form does not guarantee that a prescription will be issued;

• Cann Compounding may contact me regarding dispensing, payment, delivery or medication-related matters;

• EverPeak will only share information reasonably necessary for these purposes;

• I am not required to use Cann Compounding and may nominate another pharmacy that is legally authorised and able to dispense the prescribed medication;

• choosing another pharmacy will not affect my clinical assessment or the care provided by EverPeak, although product availability, pricing and delivery arrangements may differ; and

• I may change my pharmacy nomination before my prescription is transferred, or for future prescriptions, by contacting EverPeak.

PHARMACY PREFERENCE - Please select one:

Initials

Appointment Cancellation & Rescheduling Policy

At EverPeak, we value the time of both our patients and our Doctors. If you need to reschedule your appointment, we kindly request a minimum of 48 hours’ notice prior to your scheduled consultation. This allows us the opportunity to offer the appointment to another patient requiring care.

Appointments cancelled or rescheduled within 48 hours of the scheduled time may be subject to a cancellation fee or forfeiture of the consultation payment, at the discretion of the practice.

EverPeak is committed to providing the same level of consideration to our patients. In the unlikely event that we need to cancel your appointment within 48 hours of the scheduled consultation, we will provide you with either a full refund or a credit to your account for future use

By signing this Jotform, you acknowledge that all information provided is true and accurate to the best of your knowledge, and that you have read, understood, and agreed to the EverPeak Cancellation & Rescheduling Policy.

Signature

EverPeak Patient Medical Questionnaire

Appointment Booking: Payment is required at the time of booking to secure your appointment.*

Appointment Booking: Payment is required at the time of booking to secure your appointment.