Antidote Patient Consent Form

Patient Name*

First NameLast Name

DOB*

Date

Email*

example@example.com

Mobile Phone Number*

Please enter your mobile phone number

Medicare Number*

Your Medicare No.

What number are you in the Medicare card*

No. At the beginning of your name

Expiry Date of your Medicare*

Expiration Date

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Have you ever self-medicated or are you currently self-medicating with cannabis?*

YESNO

What other treatments have you tried for your condition(s)?*

What medications have you previously used? (List any side effects and your reason for stopping)*

Please select medical conditions that the doctor should be aware of.

Are you pregnant, breastfeeding or considering pregnancy?*

YESNO

Would you like a Video or Phone consult*

VIDEOPHONE

Patient Declaration

I understand that the long-term side-effects of medicinal cannabis are unknown.

Any verbal abuse of staff members will not be tolerated
Do not be disrespectful, threatening or disruptive behaviour towards our staff members & doctors, demanding unsafe amounts of medications.
This will result in a ban from our clinic.
I understand that medicinal cannabis is an unregistered medicine in Australia.
I understand that the quality, safety, and efficacy of medicinal cannabis has not been assessed by the Australian government's Therapeutic Goods Administration.
I understand that the prescribing doctor will report my treatment outcomes to the government.
I understand that the cost of medicinal cannabis is solely my responsibility.
I understand that I must not drive or operate heavy machinery whilst taking medicinal cannabis containing THC. If I drive under these circumstances, I am breaking the law. I understand that a legally
issued prescription does not provide a defence to such an offence.
I understand the risks and complications associated with medicinal cannabis treatment. agree to follow my doctor's recommendation regarding dosing. agree to report any adverse effects I experience from taking medicinal cannabis, including but not limited changes in the levels of sedation, lethargy, fatigue, dry mouth, nausea, vomiting, diarrhea, drowsiness, dizziness, disorientation, agitation, balance problems, changes in memory, paranoid delusions, or hallucinations.
I understand that there is a possibility of unknown risks and side effects.
I understand that medicinal cannabis might interact with my other medications, and dosage may need to be adjusted accordingly.
I agree to keep a log of my doses and changes in symptoms due to medicinal cannabis.
I agree to attend regular follow-up consultations in the clinic or over the phone as directed by my doctor.
I agree that I will not use any form of cannabis other than that prescribed by my doctor, including any illicit form of cannabis (marijuana).
I agree that I will not use any form of cannabis other than that prescribed by my doctor, including any illicit form of cannabis (marijuana).
I agree to notify my prescribing doctor of any changes in my other medications.
I agree to share my clinical outcomes for research purposes.
I have been given an opportunity to discuss my concerns.
Medicinal cannabis should remain in the original container, which has the pharmacy label (with your prescription, dosage, and script). Carrying medicinal cannabis without a pharmacy label can prove difficult.

To verify to law officials. always carry proof of prescription when travelling.
I understand and agree to the above. I confirm that all details provided in this
Consent Form are true and correct to the best of my knowledge and belief.

**Consent Form Terms**

Antidote Health Clinic is a doctor-led clinic where physicians have the autonomy to prescribe what they deem clinically appropriate for their patients. Once a medication has been prescribed, it cannot be altered unless the patient experiences a clinically significant adverse reaction to the prescribed medication. In such cases, the patient must provide valid supporting documentation for the doctor to consider changing the prescription.

Patients who are currently on Methadone, Suboxone, or any Opioid Treatment Program (OTP) medication will not be eligible for prescriptions from Antidote Health Clinic. Furthermore, any patient found misusing medical cannabis medications will be immediately banned from the clinic and will no longer receive any prescriptions or services.

A $59 fee is applicable for patients who wish to change their prescription without having experienced any clinical adverse reaction to the medication.

Date

Patient Signature