Customer Registration Form

This form is confidential and only shared with your treating practitioner and dedicated team.

This form will take roughly 5-10 minutes to complete

First name *

Surname *

Email address

Mobile Number *

Date of birth *

Address *

Street address *

City *

State *

Postcode *

Medicare Card Number *Medicare information mandatory if seeking cannabis products

Medicare Card Expiry *Medicare information not mandatory

IRN *This is the number you are list on the card

Are you an existing Hydralyfe customer? *

YesNo

I am not a professional athlete.

Gender identity? *

MaleFemaleNon-BinaryGender Diverse

Does your current gender identity differ from when you were born?

YesNo

Hydralyfe only requires this information in order to ensure the best therapeutic outcome.

Are you over 18? *

Yes No

Occupation?

Main Reason for engaging Hydralyfe ? *What are you hoping to achieve, what issues are you hoping to resolve.

Health information

Do you have any known allergies? *

YesNo

Please list allergies and describe the reaction of each

My Height in Centimeters is: *

My current weight in kilograms is: *Hydralyfe only use this information to assess the best options to include in a tailored plan.

What is your current waist size in inches?If you are unsure, please add your pant size.

How did you hear about us *

Please provide details for 'other' *

Have you had surgery in the last 12 months *

YesNo

Please Provide Some Detail

Do you have a regular general practitioner?

YesNo

Please provide the details of your GP, name, clinic, number

Do you provide Hydralyfe permission for our medical team to speak to your GP directly regarding any medical concerns?

YesNo

Last general medical check upThis can be an approximate date if unsure

Are you seeing a specialist for any conditions? *

YesNo

If yes, please provide a name and phone number.

Covid Vaccinated

YesNoRather not say

Please provide additional information that may be useful to the practitioner

Is there anything you'd like to add about your mood?

Would you be interested in plant therapy options? *

YesNo

Specifically medicinal cannabis products

Please provide details of any selections above. *

Have you used cannabis before? *

YesNo

Answering yes to this question will not preclude you from securing plant-based therapies. The Hydralyfe medical practitioner will make the decision on the efficacy of plant-based therapies for clients

What form of cannabis are you interested in? *

THCCBD and other non-psychoactive cannabinoids (CBC, CBG, CBN) Both Not Sure

Have conventional medicines/treatments failed to fully resolve your medical condition or have you avoided treatments due to negative side effects? *

YesNo

In order to be eligible conventional medicines/treatments must have failed to fully resolve your condition or negative side effects experienced. Please be prepared to discuss this during your consultation if not described here.

Have you previously sought treatment for a dependence on any drugs, prescribed or otherwise? * *

YesNo

Have you ever experienced psychosis? * *

YesNo

Note* Psychosis - a severe mental disorder in which thought, and emotions are so impaired that contact is lost with external reality

Has a close family member suffered from a psychotic illness?

YesNo

Would you be interested in us including the option for hypnosis or transformational coaching in your plan?

Yes, I'd like to know more about these services may help. No, I'm not into any of the aboveDon't know

Are you currently on a specific diet?

YesNo

If yes, what diet are you on?

Would you like us to include the option for a nutrition plan in your program quote?

Yes please I'm curious what that would cost and how it may benefitNo I know exactly what I should be eatingDon’t know

Any inclusions are for informed decision making purposed on your personalised plan they are non-obligation quotes for inclusion in your plan

What kind of nutrition plan would best suit your lifestyle?

Are there any foods you don't eat?

Do you smoke? *

YesNo

What do you smoke, how much and in what form?i.e. cannabis, dry herb vape, cigarettes, nicotine vape

Would you like us to include an option for smoking cessation (quit smoking) through our CBD/plant therapy options?

Yes, I'm curious how plant therapy might help me curb my food and/or smoking cravings. No

Please provide some details for all selections made above.

Have you or anyone in your immediate family ever had diabetes? *

YesPrediabetesNo

Please provide information about yourself or immediate family members diabetes or pre diabetes

Have you or anyone in your immediate family had heart disease? *

YesNo

Please provide information about yourself or immediate family members heart disease

Have you or anyone in your immediate family ever been diagnosed with cancer? *

YesNo

Please tell us some information about the diagnosis, treatment and current situation.

Are you currently taking any of the following medications?

Are you taking any medications or supplements other than the above? (prescribed or unprescribed) *

YesNo

We are a no judgement company focused on your health outcomes please be truthful to ensure we provide the best support and care possible.

Please list any and all medications and supplements you are taking including dosage/strength

Have you used peptides before? *

YesNo

If yes, which ones, when and did they work well for you?

Have you used anabolic steroids or hormone replacement therapies before? *

YesNo

If yes, please advise previous hormone therapy (when/what).

Are you pregnant, breastfeeding or planning a pregnancy? *

YesNo

Please select any and all that apply to you.

I drink 3 standard alcoholic drinks per day or more than 15 standard drinks per week.I use self-medicating drugs. These are not prescribed I'm frequently under stress. I sleep less than 6 hours a night. None of the above apply to me.

Please provide relevant information for any/all selections

How much moderate physical activity do you do each day?

Less than an hour1-3 hours 4-6 hours7 or more hours

What is your last known blood pressure?

What is your current resting heart rate?

Would you please tell us a little more information about the above selection.

Do you have any current or past medical conditions not mentioned above?

YesNo

Please provide more information about past medical conditions or any affecting you not listed above.

Do you suffer from any joint problems?

YesNo

Please let us know some more information about your joint pain.

Do you suffer from any injuries or pain? *

YesNo

Please describe injuries and/or pain

Are you open to using tablets and/or injections?

Photo Identity

First and middle name (if any) on identity

Surname on identity

Card number (driver's license number, proof of age card number) or passport number

Expiry date

Upload ID

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Delivery and informed consent

How would you like your products delivered if you are issued a prescription?

Please issue the prescription to the partner pharmacy and arrange a courier to deliver my product(s) to me Please hold my prescription and provide the products at a future Hydralyfe appointment Other

Please select how you would like the medication delivered and prescription received.

Delivery and/or service address if different to above

Authorised Collection Consent Form *

TeleHealth Consent Form

Disclaimer

We do not condone or support any unlawful conduct at hyDRalyfe and it’s affiliates are not inducing anyone to use plant based medications hence why we ask our visitors to familiarise themselves with their current local law before continuing. please check the Therapeutic goods association and Office of Drug Control websites for more information if you think plant-based medications is right for you, please consult with your doctor. Cannabinoids may have negative side effects or interactions with other medications for some patients. Plant based medications do not work for everyone. Cannabis interactions with other medications are currently unknown and other drugs, medications or supplements that are being taken can also interact with or be affected by cannabinoids. This form of medication is still considered, 'experimental' and the risk of addiction or dependence over time has been reported but has not been well studied. How plant-based medications affects a person and is metabolised depends on many things including their condition, size, weight, age and health, dosage, other medications and tolerance.

I understand it is my responsibility to familiarise myself with the law and any instructions on prescribed medications. I understand that I will not be able to drive or operate heavy machinery for certain periods after consuming medicinal cannabis containing tetrahydrocannabinol (THC) *

I acknowledge the legal restrictions on driving vehicles with any level of THC in my body in Australia. I agree not to operate heavy machinery or perform risky jobs/activities while taking medicinal cannabis containing THC products.

*

I hereby declare that I am at least 18 years of age and diagnosed with a condition considered to be treated by the use of medical marijuana. *

I acknowledge that medical cannabis is not a registered product in Australia and must be accessed through the Special Access Scheme or Authorised Prescriber Scheme of the Department of Health.

*

I understand that the Therapeutic Goods Administration (TGA) does not guarantee the quality, safety, and efficacy of medicinal cannabis.

*

I am aware that my treatment outcomes may be reported to the state government by the prescribing doctor.

*

I understand the risks, complications, and potential adverse effects associated with medicinal cannabis treatment.

*

I agree to follow my doctor's recommendations regarding dosing and promptly report any adverse effects, and to accept phone calls from the Hydralyfe, Tele-Green clinics and pharmacy regarding further treatment education and treatment plan.

*

I acknowledge the possibility of unknown risks in the long term of using medical cannabis.

*

I understand that medicinal cannabis may interact with other medications, and doses may need adjustment accordingly.

*

I agree not to use other forms of cannabis while on medicinal cannabis.

*

I commit to informing Hydralyfe, Tele-Green and/or Holistica Health, et, about changes in medications, any unpleasant side effects, and following up regularly with the medical team.

*

I agree not to seek medicinal cannabis treatment through another clinic while having a valid script or products from Hydralyfe, Tele-Green and/or Holistica Health, et, without proper communication.

*

I acknowledge that Hydralyfe, Tele-Green, and Holistica Health may seek permission to contact my GP or access [My Health Record] for additional medical history. I understand Hydralyfe work with many practitioners, partners and contract specialists who may access my personal and health information when relevant to my treament plan.

*

I consent to participate in a Telehealth consultation, understanding that it will involve secure electronic communication and that technical difficulties may occur. I confirm I have the necessary equipment and acknowledge the potential risks to privacy. I understand that Telehealth has limitations, such as the inability to perform physical exams, and that in-person visits may be recommended if needed.

*

I have read and fully understand the information in the Patient Consent Form and my answers are true and correct. *

Yes, I have read and fully understand the consent form and my answers are true and correctNo, I have not.

I confirm that I am over 18 years of age and not subject to any sporting or professional code where the treatments or medicines offered are prohibited.

Informed Consent Medicinal Cannabis

Date/Time *

Sign Here *

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