Sign Up Form

Sign Up
  • Patient Consent Form
  • Plan Payment

Medicinal Cannabis Treatment Consent Form​

The patient is responsible for ensuring the informed consent to Medicinal Cannabis Drugs (MCD) treatment is accurately given to medical practitioners. If signed on behalf of a patient, the signor acknowledges that he or she accepts full responsibility for MCD use on behalf of the patient.

 

Side-effects and risks

I acknowledge that:

1. MCD are generally unregistered in Australia for use in my condition by the Therapeutic Goods Administration (TGA) of the Australian Department of Health and Aging. Hence, arrangements to access MCD must be made through a Special Access Scheme pathway. The TGA has the discretion to approve the use of MCD under the Therapeutic Goods Act 1989 (Cth). However, the TGA has not assessed the quality, safety and efficacy of the MCD.

2. MCD is an experimental drug. Therefore, some treatment recommendations, side effects (including MCD use with vapourisers or other modes), risks and interactions with current medications (including use by children, pregnancy or during breastfeeding) may be currently unknown; thus, the Australian Institute of Medicinal Cannabis Pty Ltd (ACN 650 003 133) (AIOMC) trading as MiDispensary (ABN 72 650 003 133), is not liable for any damages caused by any direct and indirect use of the MCD. Further information could be obtained from the TGA at: https://www.tga.gov.au/medicinal-cannabis-information-consumers

3. Possible known temporary or permanent side-effects of MCD treatment that could be aggravated by the use of alcohol, drugs of addiction, and medication may include but are not limited to Asthenia (abnormal physical weakness or lack of energy), coordination imbalance, diarrhoea, dry mouth, vomiting or nausea, uncontrolled laughter or euphoria, increased appetite, abnormal blood pressure or heart rate, chronic bronchitis (if inhaled), confusion, disorientation, dizziness, drowsiness, vertigo, sleepiness, memory problems, cognitive impairment, anxiety, paranoid thoughts, hallucinations, psychosis, lethargy and seizures.

4. I waive and disclaim any of my rights to claim against AIOMC for any possibility of side- effects, adverse effects, and unknown risks involved in my use of MCD.


My Responsibilities

5. I am personally responsible for all costs of the MCD because I understand that the government and private health insurance may not contribute to such costs.

6. I declare that I do not have any medical conditions which are potentially dangerous or contra-indicated with MCD treatment (with delta-9-tetrahydrocannabinol), including:

  1. Hypersensitivity to cannabinoids or any other excipients.
  2. Substance or drug addiction or listed on a drug-dependent register.
  3. Known or suspected personal and family history of schizophrenia, psychotic disease or severe personality disorder 
  4. Known or suspected severe or unstable cardiopulmonary disease.


7. I acknowledge that I will:

  1. follow the doctor’s advice on dosage and frequency of MCD use;
  2. maintain a healthy lifestyle;
  3. comply with regular reviews, investigation and consultations, and blood tests;
  4. inform my doctor of all of my concurrent medications or supplements;
  5. avoid alcohol, intoxicants, or illicit and unprescribed drugs that will interact with MCD treatment;
  6. inform my doctors if MCD does not improve my condition or symptoms;
  7. report to my doctor any benefit, adverse event and side-effect that I may suffer;

8. I am personally responsible for complying with any laws concerning the operation of any vehicle (including but are not limited to boat and aircraft) or machinery while I have delta-9-tetrahydrocannabinol present in my blood or saliva or serum, or other body fluids.

9. I further agree to not claim against AIOMC for any liability concerning my operation or use of any vehicles or machinery.

10. I agree not to share/distribute, sell/trade, lend my MCD, or in any way give my MCD to any other person because I understand that these are illegal acts. I also agree that AIOMC may assist any police or/and governmental investigations concerning MCD misuse.


Personal Information


11. I understand that AIOMC collects information such as personal details and complete medical history (may include but are not limited to test results, consultation notes, conversation and observation notes, Medicare data, specialist correspondence) from me or other health care providers for the primary purpose of providing quality health care service (for example, treatment and monitoring after treatment). I further understand that my personal information will only be used for the purposes for which it was collected or as permitted by law, and AIOMC ensures that my personal information is treated with the utmost confidentiality following the Privacy Act 1988 (Cth). 

12. I, as a patient/parent/guardian, understand and agree that I am consenting to the collection of my personal information and that it may be used or disclosed by AIOMC for purposes including but are not limited to treatment, administration, billing (including compliance with Medicare requirements), disclosure as required by a court of law or other health care providers, law compliance, health care and practice management or research. 

13. I understand that if my information must be used for any purpose other than those set out above, my further consent will be obtained.

14. I understand that I am free to withdraw, alter or restrict my consent at any time by notifying AIOMC in writing.


Information

I declare that:

15. I agree that I have been and/or will be provided with all the appropriate and necessary information for providing my informed consent to my MCD treatment.

16. I agree that the use of MCD may not improve my medical condition or symptoms.

17. I confirm that I have been and/or will be provided with all the appropriate and necessary information concerning my MCD treatment.

18. I understand that I can request further information or another specialist opinion by making an additional doctor’s appointment.

19. I understand that I can request information in another language or through a translator at my own cost.

Communications

20. By using the Website at https://midispensary.com.au/ (Website), I agree that AIOMC and those acting on its behalf may send me text messages (SMS), email or other communications concerning Website operation (e.g., user account or service, updates) or promotion (e.g., developmental news). I understand that my agreement of communication is not a condition of AIOMC’s health care service delivery but will enable and facilitate AIOMC’s delivery of health care service.

Miscellaneous

21. I understand that AIOMC accepts no liability or claims for prescribing, dispensing, compounding or administering MCD products.

22. I acknowledge that my prescription, treatments or recommendations may benefit AIOMC.

23. I agree to all Terms of Use and the Privacy Policy of AIOMC on the Website.

24. I give my full consent to my MCD treatment.

Patient Details *​

Date of Birth
Signature
Legal Guardian (If Applicable)