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Patients Full Name*

Patient’s Full Name

Registration Type*

Do you have a doctors referral?*

Yes

No, but I have my medical history report

Patient Email Address *

xxxx@email.com.au

Patient Phone Number*

0400 000 000

State/Territory*

Postcode*

4000

Carer Full Name*

If you are registering for someone else, you are the carer. Please provide your full legal name (first name and surname)

Full Name

Carer Phone Number*

Consultation notifications are provided by SMS/phone calls. This will be used as the primary phone number

0400 000 000

Carer Email Address*

Please provide your email address for consultation information, information resources and booking confirmations.

xxxx@email.com.au

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*

Select Date ×

Patient Notes*

Please provide a brief summary around the patients condition, length of condion/symptoms and any previous or current treatments/medications.

Where did you hear about us?*

Other (Please Specify)*

Please Specify

After this registration, the next step is to book in a call with your amazing support team to go through dates and times available for your medicinal cannabis telehealth or in-clinic consultation with PlantMed.

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 sign up for our information pack here to complete later. Otherwise please upload the completed documents below.

What forms have you completed?*

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.

I have completed the forms

I am yet to complete the forms

My GP will not refer me

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

Drag ‘n Drop files here

Max file size: 9.54 MB. | Allowed file types: gif,jpeg,png,jpg,pdf | Min number of file: 1

Select Files

Attach Health Summary

Drag ‘n Drop files here

Max file size: 9.54 MB. | Allowed file types: gif,jpeg,png,jpg,pdf | Min number of file: 1

Select Files

Attach Consent Form

Drag ‘n Drop files here

Max file size: 9.54 MB. | Allowed file types: gif,jpeg,png,jpg,pdf | Min number of file: 1

Select Files

When you click submit, a submission confirmation will appear and allow you to book a time with our friendly support team to organize an appointment time to with a doctor.

Book an appointment with PlantMed

Attach Referral Letter

Attach Health Summary

Attach Consent Form

Your forms have been submitted please book in a call with our team below

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