Medicinal Cannabis Consent Form

• Please read this form carefully before you attend your consultation with the doctor.

• You should  mark the box at the end of each page to indicate that you have read and understood that section.

• You will have the opportunity to discuss any specific questions or concerns that you may have when you talk with the doctor

Overview of Consent Form 

The primary objective is to provide necessary information within the consultation, to allow you to make informed decisions and to consent to Medicinal Cannabis (MC) treatment. 

Further objectives are: 

1. to describe the benefits, risks and possible complications of the treatment 

2. to explain your responsibilities

3. Explain the fee structure 

Consultation Fees and payment: 

In Person Initial Consultation- $240 with a medicare rebate of  $80.10

Telehealth Initial Consultation- $240 with a medicare rebate of $41.40

* Prepayment required prior to securing an appointment

Standard follow up consultations- $120 with a medicare rebate of $41.40

 Longer or complex follow up- $195 with a medicare rebate of $80.10

 Follow up requiring additional approval- $240 with a medicare rebate of $80.10

Prescription Fees: The cost of Medicinal Cannabis is not included in your consultation fee, and you can expect to pay between $4.00 and $10.00 per day.

For queries regarding your consultation please contact Specialty Team on 07 5616 8070

Benefits, Risks and Possible Complications of Medicinal Cannabis

I acknowledge that:

1. MC is currently considered an experimental or investigational product, and in many cases, there is limited data from which to draw specific recommendations for treatment. Visit www.tga.gov.au/medicinal-cannabis-guidance-documents for more information. 

2. In general, MC is not registered in Australia for use for my condition by the Therapeutic Goods Administration of the Australian Department of Health and Ageing (TGA). Permission to prescribe MC is only granted through a Special Access Scheme (SAS) pathway. 

3. Use of MC in children, pregnancy, and breast-feeding is not well investigated. 

4. MC may interact with my current medications and cause side effects. 

5. Possible side-effects of MC particularly with Delta-9-Tetrahydrocannabinol (THC) may include and are not limited to: Asthenia (abnormal physical weakness or lack of energy), Confusion, Disorientation, Dizziness, Drowsiness, Vertigo, Balance problems, Coordination problems, Memory problems, Diarrhoea, Dry Mouth, Fatigue, Hallucinations, Paranoid thoughts, Increased appetite, Cannabis use disorder, Cognitive impairment, Chronic bronchitis (if inhaled or smoked), Nausea, Light-headedness, Uncontrolled laughter or Euphoria.

Your Responsibilities

 I have had ample opportunity to discuss MC treatment and my personal health. I agree to the following: 

1. I declare that I do not have any of the following medical conditions which are potentially dangerous or contra-indicated with THC containing MC: 

- Hypotension (low blood pressure)

- Cannabis misuse or addiction

- History of schizophrenia or psychotic illness

- Family history of schizophrenia or psychotic illness

- Unstable or severe heart disease. 

2. I will have regular monthly reviews with my prescribing doctor, unless otherwise instructed. 

3. I will carefully follow my prescribing doctor’s advice on dosage and frequency of MC. 

4. I guarantee I will maintain a healthy lifestyle that will help my condition/symptoms. 

5. I will avoid alcohol, intoxicants, or recreational medications that will interact with MC treatment. 

6. I will follow my prescribing doctor’s advice on blood testing for investigations. 

7. I will inform my prescribing doctor about all the medications/supplements I am taking. 

8. I will inform my prescribing doctor if MC does not work for my condition/symptoms. 

9. I will report to my prescribing doctor if I suffer an adverse event, side-effect, and reactions. 

10. I will be aware and adhere to all laws relating to the operation of any: vehicle, aircraft, machinery, etc., regarding the use of THC or MC and blood, serum, saliva, or other levels. 

11. I further agree that it is my responsibility to adhere to all laws.

Final Declaration 

I declare: 

1. All the necessary information has been provided to make an informed decision. 

2. I have been advised of the appropriate dosage. 

3. I understand the potential benefits, risks and possible complications of the treatment. 

4. I agree that MC may not work for my medical condition. 

5. I confirm that my doctor has provided me with all appropriate information concerning MC treatment. 

6. I am satisfied to fully consent to MC treatment. 

 7. I have had the opportunity to make further requests for information. I do not have any further requests for information on MC treatment, at this time. 

8. It is my responsibility alone to ensure I comply with all the laws, work contracts, safety guidelines, etc., regarding MC treatment and THC levels within my body. 

9. I agree not to share, sell, lend, trade, transport/ship MC or in any way give my MC to any other person. I realise this is an illegal act. I also agree that my doctor and my pharmacist may work with the Police to investigate any alleged misuse or sale of my MC. 

10. If signed on behalf of a dependant person, I acknowledge that I accept full responsibility for MC use of the dependant patient.11. I have been advised and understand that it is an offence, under section 79(2AA) of the Transport Operations (Road Use Management) Act 1995 (Qld) (or equivalent State or Territory legislation) for a person to drive, attempt to put in motion, or be in charge of a motor vehicle, tram, train or vessel while that person has THC present in the person’s blood or saliva.

**Please do not sign. You can submit this without a signature and you will be required to sign in front of the Doctor in the consultation**