Referral Form

This referral form is here to connect health professionals directly to our clinic. Once provided our team will get in touch to organise a booking on behalf of your patient. If you are unsure at all about your referral, feel to contact us directly.

Client Information (Required)

DD slash MM slash YYYY
Does your patient have any history of substance use disorder, complex psychiatric history, suicidal ideations or high risk for falls?(Required)

Referrer's Name (Required)

Referrer Declaration (Required)

This referral includes an approved indication of medicinal cannabis where first line treatment have failed to provide net benefit for the patient we need a qualified medical professional to sign it. We will consider this electronically completed form to be signed by the health professional's named in this section.

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