Request an Appointment & Consent Form

Please have your Driver's license & Medicare card (if you have one).

First Name *

Last Name *

DOB *

Phone Number *

Email Address *

What is your address? *

Please provide your 10 Digit Medicare Number? *If you do not have a Medicare number please put 10 Zeros MEDICARE NUMBER IS COLLECTED TO VERIFY and CHECK USE OF MONITORED MEDICINE on QSCRIPTS!

Please enter your position on Medicare card (URN)? *

Please state Medicare Card Expiry Date? *MM/YYYY

Please provide a GP Medical summary from your current doctor

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Please Upload a Photo of your Drivers License? *

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Please only upload name and Date of Birth - We do not require DL Number. We will destroy information once confirmed.

I confirm and agree that I am not procuring medication/treatments through multiple clinics for the same conditions for either personal use or on selling and understand that it would be illegal to do so and would result in immediate termination of any relationship with Optimal Health Clinic (OHC) *

Do you Give Consent for Optimal Health Clinic Medical Team to Access 'My Health Record' in the Interest of Patient Safety? *

YESNO

Consent will allow your Doctor to view your medical records and current medications to make informed diagnosis and prescribe appropriate treatments. Access to medical records is only obtained during consultation and while you are a current patient. Your file is kept completely confidential throughout the entire process.

Reason for appointment *

Please choose a consult option: *

ALTERNATIVE MEDICINE CONSULT (FREE)

Annual Consultation period including all fees EXCEPT MEDICATION. A consult consists of the intake, onboarding, review, recommendations and possible scripting of medications as well as phone consultations with your Dr and our team if necessary. A single consultation is conducted once only with any further communication of repeat scripting needing to be booked in as another consult. A 6 month consultation period is required for ongoing clients and this is covered in the annual fee. The annual fee allows for multiple bookings and on demand review over that period of time. The Fee includes but is not limited to: - phone consults with the team - phone consult with an Australian Doctor - Clinic Liaison with external and allied professionals (pharmacy, GP, Physiotherapist, Dietician) - Sending orders - Posting paperwork or scripts if required - Uploading files and record keeping - Managing bookings and request * Six Monthly & Three Monthly Fee Schedule has been built to make working with us more affordable. Same rules Apply as the Annual Fee Schedule *Terms and Conditions Apply - Enquire with team for full details and refer to the Terms and Conditions Apply, FAQs on Website

What is your Biological Gender? *

MaleFemale

Are you currently Pregnant and/or Breastfeeding or planning to concieve? *

What is your occupation/Job? *

What is your Height in CM? *

What is your current weight in KG? *

What was your last Blood Pressure Reading? *

Do you have any allergies? *Please indicate if you currently suffer or have suffered from an allergic reaction as a result of any allergen? Please state the allergen and reaction.

You may upload your Results or medical files here.

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Describe your Current Lifestyle: *Describe your lifestyle and daily/weekly habits, such as sleep, work, family time, hobbies

Describe your current Diet: *Describe your diet choices including breakdown and sources of calories. List any special diet programs you are currently following.

Describe your current Health status Including any medical issues: *Describe your current symptoms or concerns. List any previous surgeries, recent/previous diagnosis and any current health conditions that are impacting your current quality of life

List any Medications, Vitamins or Supplements you take: *

How many drinks (alcohol) do you consume a week? *

Do you use cannabis? *

Are you or have you ever self-medicated with Cannabis?

Have you tried any medication/treatment to treat your condition? *

Was there any side effects? *

Do you engage in the use of recreational drugs? *

What is your smoking status? *

What are your Health Goals with Medicinal Cannabis? *

Consent *

I understand that the long-term side-effect of medicinal cannabis is unknownI understand that medicinal cannabis is an unregistered medicine in AustraliaI understand that I must not drive or operate heavy machinery while taking medicinal cannabis containing THC. I understand that a legally issued prescription does not provide a defence to such an offenceI understand the risks and complications associated with medicinal cannabis treatment. I agree to follow my doctors recommendation regarding dosing. I agree to report any adverse effects I experienceI understand that medicinal cannabis might interact with my other medications and may need to be adjusted accordinglyIf I proceed with treatment, I agree to notify my regular Doctor that I am being treated with medicinal cannabisI agree to share my clinical outcomes for research purposesI agree to report any changes in symptoms due to medicinal cannabis to my doctorI declare that all answers in this consent form are true and correct to the best of my knowledge and belief

I Consent to Optimal Health Clinic Pty Ltd handling of my personal information in accordance with their privacy policy *

Pharmacy Preference *

OHC Partner PharmaciesMy Local Chemist

Contact Details of Chemist

Agent Agreement Confirmation *

Clear

The individual filling out this form and/or who's Identification has been supplied consents and/or agrees to OHC (Optimal Health Clinic), its Director, Staff, Contractors and associated partners to act as their agent. You agree to giving consent for the agent to act on your behalf with Doctors, Pharmacists, Allied Health Professionals within the interest of your enquiries and in accordance with the Australian Privacy Act. You acknowledge that you understand the team at OHC comprise of contractors and Admin staff who are not Doctors and can't/will not provide medical advice. You agree for the team to act as an agent in liaising with your Doctor/s, the pharmacies and other partis at your instruction and in your best interests.

*PLEASE NOTE: BODY ENHANCEMENT/PERFORMANCE ENHANCEMENT IS NOT A SUITABLE GOAL AND TREATMENT WILL NOT BE PRESCRIBED BY A DOCTOR FOR THIS PURPOSE *

I agree to attend my regular Doctor (GP) or Specialist for full heath Check
I agree to have any checks they deem necessary including but not limited to, Blood pressure, Cholesterol, Heart Check, ECG, Physcial examination, Pathology Request *

Please confirm you have read and agree to terms in our Medical Practice Privacy and Consent Form *

I would like a Copy of the SOP

Waiver/Disclaimer *

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By Filling this form, I agree to only using the medication/treatment prescribed to me, if any, in the correct and safe manner as ordered by the Doctor. I agree that the information and medication are only for me and that I will not sell, share or distribute medication/protocol to any other parties. I agree to use medication at the prescribed dose only and to report any side effects or adverse reactions to the pharmacy.

For security please complete the check below *

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