Maroochydore Registration

/ Maroochydore Registration

CDA Clinics Maroochydore

Registration Form

Step 2 of 4
Patient Email**
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Patient Phone Number old**
Patient Phone Number**
State/Territory**
Postcode**
Carer Name**
If you are registering for someone else, you are the carer. Please provide your full legal name (first name and surname)
Carer Phone**
Consultation notifications are provided via SMS / Text Message. This will be used as the primary phone number
Carer Email**
Please provide your email address for consultation information, information resources and booking confirmations.

Step 3 of 4
Please provide a brief summary around the patients condition, length of condition/symptoms and any previous or current treatments/medications.
Patient's Gender**
Patient's Date of Birth*

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What is your primary condition diagnosis?**
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Other primary condition**
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How long has the condition lasted?**
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What are your primary symptom/s?**
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Other primary symptoms**
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Do you have any previous experience or knowledge of Medicinal Cannabis?**
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Which cannabinoids are you interested in discussing with our doctors?**
Extra Notes (Not Required)
How did you hear about us?**

Step 4 of 4
After this registration, the next step to access medicinal cannabis is a telehealth or in-clinic consultation with CDA Clinics. To book this consult, we will need:
- a referral letter from your GP
- a relevant health summary
- a consent form signed by you
If you don't have these forms yet, no problem - just tick the box below and we'll email you a copy of the forms to complete later. Otherwise please upload the completed documents below.
Form Completion*
- I am yet to complete the forms
- I have completed the forms
Document Upload
Please tick the relevant boxes for the forms you have completed to upload them.
- Referral Letter
- Health Summary
- Consent Form
Attach Referral Letter
Max. file size: 10 MB.
Attach Health Summary
Max. file size: 10 MB.
Attach Consent Form
Max. file size: 10 MB.
Consent**
- I agree to the CDA Health and CDA Clinics Privacy Policy and Trading Terms & Conditions.
When you click submit, a submission confirmation will appear on a new page. Please wait for this before clicking submit again.
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Business Owner - Hidden
- CDA Clinics
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