Medical Cannabis patient intake form
We collect information that is sent to approved cannabis doctors who are able to prescribe all Australian Therapeutic Goods Administration (TGA) approved cannabis medicines, ensuring a range of treatment options best suited to each patient’s condition and desired treatment outcome. Medical Cannabis patient privacy policy https://www.medicinalorganiccannabis.org/about-moca/patient-privacy-policy
Medicinal Organic Cannabis Australia (MOCA)
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Email Address *
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Residential Street Address
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Suburb
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City
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Post Code
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Treating specialist name, phone, & email (if known)
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Treating GP name, phone, & email (if known)
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Pharmacy name, phone, & email (if known)
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List all current medications and side-effects
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Medical History- List any illnesses, injuries or operations
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Allergies or allergic reactions - please list
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Reason for visit - Please list any symptoms
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If you have ever been diagnosed with cancer please state grade and type of cancer
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If you have ever been diagnosed with epilepsy, please describe seizures
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Have you ever tried cannabis before?
Please list any cannabis use - how much and how often?
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Please list any other relevant information you can think of in relation to your disease
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This form was created inside of Medicinal Organic Cannabis Australia (MOCA).