GENERAL APPOINTMENT ONLY: Request an Appointment & Consent Form

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 Enter the Medicare Card Expiry Date? *MMYY

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: *

GENERAL SINGLE CONSULT $125 INC GST

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. 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 *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

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 current Diet: *

Describe your current Health status Including any medical issues: *

List any Medications, Vitamins or Supplements you take: *

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

Do you engage in the use of recreational drugs? *

What is your smoking status? *

What are your Health Goals *

Pharmacy Preference *

OHC Partner PharmaciesMy Local Chemist

Contact Details of Chemist

Agent Agreement Confirmation *

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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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