Refer your patient

If you have a patient who could benefit from this new treatment, please complete the referral form below and one of our team will be in touch in the coming week to assist your patient.


    First Name

    Last Name

    Date of Birth

    Mobile Phone Number



    I have been seeing the patient as usual practitioner for at least the past 3 months.

    I have access to enough past medical history to support this referral

    Other available conventional treatment options have been used previously.

    Previous treatment outcomes:

    Qualifying medical conditions
    Alzheimer's DiseaseAnorexiaAnxietyADHDASDCachexiaCancer symptom managementCancer-related painChemotherapy-induced nausea / vomitingChronic non-cancer painCrohn's diseaseDementiaDepressionEndometriosisEpilepsyInflammatory bowel disease (IBD)InsomniaIrritable bowel syndrome (IBS)Mood disorderMultiple sclerosis (MS)Neuropathic painOsteoarthritisPalliative careParkinson's diseasePTSDSeizure managementSleep disorderSpasticitySpasticity-associated painOther

    Please specify other

    Warning signs
    NilSuicide attempt/sSuicidal ideas / intentsDrug dependence / Substance abuseSevere COPD / Asthma

    Contraindications (Please do not refer a patient if a contraindications is ticked or if contraindications are ticked)

    Current or history of:
    NilSchizophreniaAcute psychosisUnstable severe bipolarMyocardial infarction
    NilUnstable anginaAngina pectorisPregnancy / BreastfeedingPlans for imminent pregnancy

    Symptoms management strategies so far
    Non-opioid AnalgesicsNSAIDsOpioid analgesicsSurgical intervention/sUS-Guided injection/sCT-Guided injections/sNerve pain agentsAnti-depressantsAnxiolyticsSleeping agentsPsychotherapy / CBTOther

    Please specify other

    Specialist/s involved
    NilOrthopaedic / Spinal surgeonPain specialistNeurologistOncologistPsychiatristGastroenterologistSleep PhysicianGynaecologistOther

    Please specify other

    Allied Health Providers involved
    NilPhysiotherapistChiropractorExercise PhysiologistOccupational TherapistPodiatristDieticianPsychologistOther

    Please specify other

    Patient currently / has been previously using cannabis.


    From - to




    Doctor Name

    Practice Name

    Practice Phone Number

    Practice Fax Number

    Practice Email

    Referral date

    Please upload a copy of the patient's Health Summary

    Or download the form here and email us a copy

    Prefer to call us?

    You can get in touch during office hours on (07) 3059 1301

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