Dr Shu: New Patient Registration Form

New Patient Registration Form

Please complete this form to help us create a medical record and have enough background information to facilitate discussion. Please note all information is stored and handled privately and confidentially according to HIPAA and The Privacy Act 2014.
Mandatory Pre-Consultation Readings

https://linktr.ee/drshu

Please read the one page Introduction sheet and/or watch the Pre-Consult Intro Video. This ensures that the consultation time is dedicated to tailoring medications to your needs, rather than going through the basics. This must be completed prior to the consultation.
I confirm that I have/will review the pre-consultation reading and video.

Yes I confirm
Name *

First Name Last Name
Date of Birth *
dd/mm/yyyy
Gender *
Email *
example@example.com
Contact/Mobile Number *
Full Residential Address (Including Suburb & Postcode) *
Medicare and reference number for prescription purposes, or IHI number (if no medicare, please let us know reason *

Medical History
GP name and practice details
What is the diagnosed medical condition(s) you are looking to treat with medicinal cannabis? How long since you have been diagnosed? *
Briefly describe your symptoms and how the above-mentioned conditions impact your daily activities. *
What other medications/treatments have you trialled for the above condition(s)? *
Other current and previous significant medical conditions, including mental health disorders, any previous history of psychosis, etc *
Current medications, doses if possible *
Allergies or adverse reactions to medications or food *
Family history of mental health conditions *

Social History
Who lives at home with you? Do you have any dependents/children? *
Occupation *
Smoking status - current/ex/non; how many a day if current *
Alcohol consumption per week *
Current and previous illicit/non-medicinal or recreational drug use? If you use cannabis currently, please detail how/when you use it and how much you might use per day *
Height and weight *
How did you hear about Dr Shu? If you have been referred by a pharmacy please specify which pharmacy.
Do you prefer a phone or video consultation? The Google Meet video link is sent the day before with the appointment reminder email. *

Phone / No preference (default will be a phone appointment) Video
Medicinal Cannabis Experience

This does not necessarily affect what type of medications you may be prescribed, but helps to facilitate the consultation and discussion
How much knowledge/experience do you have in cannabis? *

I am very experienced and have a fair amount of knowledge about cannabis I have some experience and knowledge about cannabis I have very little to no experience and knowledge about cannabis
What type of medicinal cannabis products are you interested in? *

Cannabidiol (CBD) Tetrahydrocannabinol (THC) CBD and THC I'm not sure yet
Document Upload
If you have a referral or any documents to upload, please upload here.

Cancel of

Declaration and Consent

Please read the following information below as an acknowledgement of your understanding of Dr Shu's services and are happy to proceed with cannabinoid-based therapy
By submitting the patient registration form including declaration and consent:

I consent to treatment with medicinal cannabis/cannabinoid medications.

I understand that medicinal cannabis may not work for me; there is limited evidence on the efficacy of medicinal cannabis and is not the first line treatment for any medical condition. Acute and long term side effects are not well-known and I accept full responsibility for any risks associated with use of medicinal cannabis.

I understand that medicinal cannabis is still an unregistered medication in Australia by the Therapeutic Goods Australia (TGA). Therefore, access to medicinal cannabis need to be made through a Special Access Scheme or Authorised Prescriber scheme.

I agree to have regular follow-ups as indicated by Dr Shu, and report any adverse effects and changes to other medications. Dr Shu may report my treatment outcomes to the state government.

I understand that the cost of medicinal cannabis or organising reimbursement by third parties is solely my responsibility.

I understand that medical cannabis can impair my ability to drive, operate other vehicles/heavy machinery, or make important decisions. It is an offense to drive in Australia with any level of tetrahydrocannabinol (THC) in my blood, urine or saliva. A legally issued prescription is not protective against these laws.

I will adhere to State and Federal legal requirements pertaining to medicinal cannabis.

I understand that medicinal cannabis interactions with other medications are not well known, and I accept risks associated with any interactions that may occur.

I agree to share my clinical outcomes for research purposes.

I agree to receive communications from Dr Shu in the form of SMS, email, post and telephone

I understand that if I do not provide at least 24 hours’ notice to cancel or change my appointments I will be charged a nonrefundable cancellation or ‘no show’ fee.

I understand that aggressive behaviour is not tolerated and could result in discharging me from the practice.

I declare that all answers provided in the registration form and during the consultations are true and correct to the best of my knowledge and belief.
I declare that all answers provided in the registration form and during consultation are true and correct to the best of my knowledge and belief.

Yes
Signature Declaration (use mobile device or mouse to sign) *

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