Novel Therapies Australia Information Form

1
Are you a returning patient?If you have used our service before please click yes.
YESNO
2
Are you above 18 years of age?* This field is required.If under 18 years of age, you will not be able to proceed. Our online consultations are only avaialble to those 18 years and older.
YESNO
3
Do you have a chronic medical condition that has been causing you distress for a minimum of 3 months?* This field is required.This consultation service is only for those with chronic pain or chronic anxiety that has presented for over three (3) months.
YESNO
4
Brief Description Of Chronic Condition* This field is required.Have you had a previous diagnosis, and what is it. Please aslo describe the condition and symptoms.
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5
How have you tried treating your condition?* This field is required.Please choose the one that is most accurate.
I have used Prescription medication.
I have tried alternative therapies including (but not limited to) physiotherapy, psychological therapy, chiropractor, naturopath and osteopaths.
I have not treated this condition because I dislike prescription medication, and haven't considered other therapies.
I have not treated my condition.
6
During your treatment, were you...* This field is required.Please choose which best describes any prior treatment.
Unsuccessful in fully treating your condition
Experiencing unwanted side effects
Self-treating through non-prescribed medicine
Has not been treated.
7
Are you pregnant, or is it possible you may be pregnant?* This field is required.If unsure, please undergo a pregnancy test before proceeding further. Some treatments may have adverse effects on pregancy, and unborn children.
YESNO
8
Do you have a history of schizophrenia, bipolar type 1 and 2 disorder or have experienced psychosis?* This field is required.Psychosis - a severe mental disorder in which thought and emotions are so impaired that contact is lost with external reality.
YESNO
9
Have you used this online consultancy service before?* This field is required.
YESNO
10
What was the previous visit for?Please choose one answer.
Initial Consultation
First Month review
Ongoing Review Consultation
11
Do you have any cardiac conditions* This field is required.If yes, we will ask for details in the next question.
YESNO
12
Please describe the cardiac condition you have been diagnosed with
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13
Are you breastfeeding?* This field is required.Some treatments may affect what your child absorbs into their body and brain.
YESNO
14
Do you have a regular GP?* This field is required.
YESNO
15
GP Name & ClinicPlease give us the name of your GP and the name of the medical centre they are a practitioner at.
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16
The next questions will be used so that we can connect with you once you have paid for and booked your appointment. You will be asked to agree to a privacy disclosure agreement with Novel Therapies Australia. Please ensure you read it and agree to it so we can proceed to the booking.

During the initial consultation we will also collect your medicare information to allow you to claim back a portion of the consultation fee.
17
Privacy Consent* This field is required.You will need to read all the text and scroll to the end before you can tick the consent.
18
Name* This field is required.Please add your full name.
First Name
Middle Name
Last Name
19
Email* This field is required.Please add your email address so we can confirm your appointment.
example@example.com
Email Verified
The verification code has been sent to some@email.com
Please check your mailbox and paste the code below to complete verification
••••
Didn't receive verification code?or
Receiving the email may take a few minutes, thank you for your patience!
20
Phone Number* This field is required.Mobile or landline
Please enter a valid phone number.
21
Date of Birth* This field is required.
Date
Day
Month
Year
22
The next page will have on it the different consultation options:

Initial Consultation (for those who have not used this service before.)

First Month Follow Up Consultation

Ongoing Monthly Review Consultation

The following form has 3 pages:

Page 1 - Initial Consultation

Page 2 - First Month Follow Up

Page 3 - Ongoing review

Please navigate to the option you require.

Once you have chosen which consultation you require you will be taken to the payment details where you can use a credit or debit card.

Once payment has been accepted, you will be emailed a confirmation and receipt, and then you will be taken to the booking page to book your appointment.
23
Available Consultation TypesPlease choose from one of the types of consultation below. If this is your first time using our services, you need to choose the "Initial Consultation". Once we have completed your first consultation, you can choose the first month review, or the ongoing monthly review.
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ORDER SUMMARY
Total costAUD
Initial ConsultationInitial Online Consultation with one of our team of doctors to obtain a treatment protocol for an existing chronic condition. This consultation will be to:• Register as patient.• Complete patient form for Medicare,• Assess your condition,• Assess treatment options
$99.00AUDEdit
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End Of First Month ReviewEnd of first month Review Online Consultation with one of our team of doctors to assess ongoing treatment of an existing chronic condition. This consultation will be to:• Assess progress• Re-assess your condition if necessary
$60.00AUDEdit
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Ongoing monthly reviewOngoing review of a chronic condition and assessment of any changes required for treatment.
$60.00AUDEdit
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Total cost $0.00AUD
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