New patient form

Please complete this before your first appointment. It takes about 5 minutes.

Fields marked * are required. Need help? Email support@hellothc.au.

Patient details

Title *

Preferred name

First name *

Middle name

Surname *

Date of birth *

Gender *

Email *

Mobile phone *

Other phone

Time zone *

Introduction source *

Address & contacts

Street address *

Suburb *

State *

Postcode *

Occupation

Emergency contact name

Emergency contact phone

Emergency contact relationship

GP name

GP clinic

Share with GP

YesNoI don't have a regular GP

Health information

Reason for visit *

Duration of condition

Previous treatments

Other conditions

Current medications *

Allergies *

Have you or a close family member ever been diagnosed with schizophrenia, bipolar disorder or psychosis?

NoYes, meYes, a family memberUnsure

Heart condition

YesNo

Are you pregnant, planning pregnancy, or breastfeeding?

NoYesNot applicable

Prior medicinal cannabis *

No, neverYes, prescribed by a doctorYes, but not prescribed

Prior cannabis details

Previous clinic

Social habits

Do you smoke tobacco or vape nicotine?

NoYesEx-smoker

Alcohol per week

Other substances

Do you drive a vehicle or operate machinery?

YesNo

Note: in Australia it is illegal to drive with any THC in your system, even with a prescription. Your doctor will discuss this with you.

Workplace drug testing

Medicare & concession

Medicare number *

Medicare IRN *

Medicare expiry *

Concession

Concession number

Consent * Required

I consent to Thrive Holistic Centre collecting and storing my health information for the purpose of my care, in line with the Australian Privacy Principles.I consent to my prescription being sent electronically to a partner pharmacy for dispensing, and to the pharmacy contacting me about my order.I understand consultations are by telehealth (phone or video), that a prescription is not guaranteed, and that any decision is made by the doctor based on my clinical suitability.I confirm the information above is true and complete to the best of my knowledge.

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