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Treatment Consent Form

Medicinal Cannabis

Overview of Consent Form

This form provides the information necessary (in conjunction with the clinical consultation) to enable patients to make an informed decision and consent to medicinal cannabis treatment. This form also:

  1. Describe the risks and possible complications of the treatment.
  2. Explain the patient’s responsibilities.
  3. Establish a patient registration scheme for patients.
  4. Explain our duty of care and consents, including gathering personal and medical information and contact for communications.
  5. Acknowledge that this consent form covers all aspects of medicinal cannabis prescription and all related practices undertaken by Southern Cross Cannabis Clinic.

Benefits, Risks, and Possible Complications of Medicinal Cannabis

I acknowledge that:

  1. Medicinal cannabis is generally considered an experimental or investigational drug, and, in many cases, there is limited data from which to draw specific recommendations for treatment. For more information you can visit:
  2. Medicinal cannabis drugs are, in general, not registered in Australia for use in my condition by the Therapeutic Goods.
  3. Administration (TGA) of the Australian Department of Health and Ageing, and as such arrangements to access to medicinal cannabis medicines are generally to be made through a Special Access Scheme (SAS) pathway. The TGA have the discretion to allow such approvals under the TGA Goods Act 1989
  4. Medicinal cannabis benefits and harms in children, pregnancy and breast-feeding are not well investigated and Southern Cross Cannabis Clinic will not be held liable for any damages or claims relating directly or indirectly from medicinal cannabis use.
  5. Medicinal cannabis may interact with my current medications and cause side effects from these medications
  6. Medicinal cannabis use with vaporisers or other modes of use may cause known or unknown side effects.
  7. I waive and disclaim any of my rights to claim against Southern Cross Cannabis Clinic and this practice for any possible of side-effects, adverse effects, and unknown risks involved in taking medicinal cannabis.
  8. Possible known side-effects of medicinal cannabis compounds, principally with Tetrahydrocannabinol (THC), may include and are not limited to: nausea, light-headedness, uncontrolled laughter or euphoria, dry mouth, increased appetite, vomiting, relaxation, sedation, drowsiness, abnormal blood pressure, physical weakness, confusion, disorientation, dizziness, vertigo, coordination imbalance, memory changes, cognitive impairment, bowel changes, anxiety, hallucinations, paranoid thoughts, psychosis, mental disturbance, abnormal heart rate, lethargy, seizures, and chronic bronchitis (if inhaled).

Patient Responsibilities

It is my responsibility to ensure that I listen to the doctor, clinical staff and pharmacist in the consultations. I have had and/or will have a good opportunity to discuss and explore medicinal cannabis treatment for my personal health; and I agree to the following:

  1. I declare that I do not have any medical conditions which are potentially dangerous or contra-indicated with medicinal cannabis treatment, principally THC, including:
    • Hypersensitivity to cannabinoids or any type of excipients.
    • Substance addiction or the intentional use of drugs for non-medical purposes.
    • On a drug-dependent register.
    • Known or suspected personal history of schizophrenia or psychotic illness.
    • Known or suspected family history of schizophrenia or psychotic illness.
    • Known or suspected personal history of severe personality disorder.
    • Known or suspected severe or unstable cardio-pulmonary disease.
  2. Regular reviews with my cannabis doctor as instructed or as required.
  3. To carefully follow the clinician’s advice on dosage and frequency of medicinal cannabis.
  4. Maintain a healthy lifestyle that will help my condition or symptoms.
  5. Avoiding alcohol, intoxicants, or recreational drugs that will interact with medicinal cannabis treatment.
  6. Follow my cannabis doctor’s advice on blood testing or additional investigations.
  7. Ongoing consultation with my referring doctor or specialist.
  8. Informing my cannabis doctor of all concurrent medications or supplements.
  9. I will inform my doctors if medicinal cannabis does not work for my condition or symptoms.
  10. I will report if I suffer any adverse event, side-effect and reactions to my cannabis doctor.
  11. I am aware and will comply with any laws relating to the operation of any: vehicle; boat; aircraft; machinery; or other regarding the use of THC or medicinal cannabis and blood, serum, saliva, or other levels. I further agree that it is my responsibility and I release Southern Cross Cannabis Clinic Group and this practice from any liability in relation to the operation or use of any vehicles or machinery.

Consent to Gathering of Personal and Medical Information

It is my responsibility to ensure that I listen to the doctor, clinical staff and pharmacist in the consultations. I have had and/or will have a good opportunity to discuss and explore medicinal cannabis treatment for my personal health; and I agree to the following:

  1. Southern Cross Cannabis Clinic and this practice collects information from you for the primary purpose of providing quality health care. We require you to provide us with your personal details and a full medical history so that we may properly assess, diagnose and treat illnesses and medical conditions, ensuring we are proactive in your health care. To enable ongoing care, and in keeping with the Privacy Act 1988 and Australian Privacy Principles, we wish to provide you with sufficient information on how your personal information may be used or disclosed and record your consent or restrictions to this consent.
  2. Your personal information will only be used for the purposes for which it was collected or as otherwise permitted by law, and we respect your right to determine how your information is used or disclosed. The information we collect may be collected by a number of different methods and examples may include: medical test results, notes from consultations, Medicare details, data collected from observations and conversations with you, and details obtained from other health care providers (e.g. specialist correspondence).
  3. By signing below, you (as a patient/parent/guardian) are consenting to the collection of your personal information, and that it may be used or disclosed by Southern Cross Cannabis Clinic and the practice for the following purposes:
    • Administrative purposes in the operation of our general practice.
    • Follow-up reminder/recall notices for treatment and preventative healthcare, frequently issued by SMS.
    • Disclosure to others involved in your health care, including treating doctors and specialists outside this Medical Practice. This may occur through referral to other doctors, or for medical tests and in the reports or results returned to us following the referrals.
    • Accreditation and quality assurance activities to improve individual and community health care and Practice Management.
    • For legal related disclosure as required by a court of law.
    • For the purposes of research only where de-identified information is used.
    • To allow medical students and staff to participate in medical training/teaching using only de-identified information.
    • To comply with any legislative or regulatory requirements, e.g. notifiable diseases.
    • For use when seeking treatment by other doctors in this Practice.
  4. At all times we are required to ensure your details are treated with the utmost confidentiality. Your records are very important, and we will take all steps necessary to ensure they remain confidential. Please sign below if you understand and agree to the following statements in relation to our use, collection, privacy and disclosure of your patient information.

Final Declaration

I declare that:

  1. I agree that all the necessary information has and/or will been provided to me to make an informed decision.
  2. I will carefully follow the advice of my cannabis doctors on medicinal cannabis dosage and frequency.
  3. I understand the potential risks, possible side effects and complications of medicinal cannabis treatment.
  4. I agree that medicinal cannabis may not work for my medical condition or symptoms.
  5. I confirm that I have been and/or will be provided all the appropriate information concerning medicinal cannabis treatment, and I am satisfied to fully consent to this treatment, and I have had and/or will have the opportunity to make further requests for information and prior to starting medicinal cannabis.
  6. I consent to personal information being shared with health professionals, government or Southern Cross Cannabis Clinic affiliates for the purposes of application, compliance, health or sundry.
  7. I have read the information above and understand the reasons why my information must be collected, and the purposes for which my information may be used or disclosed. I understand that if my information is to be used for any purpose other than that set out above, my further consent will be obtained.
  8. I give permission for my personal information to be collected, used and disclosed as described above, including contact via SMS to my mobile phone number. I understand only my relevant personal information will be provided to allow the above actions to be undertaken and I am free to withdraw, alter or restrict my consent at any time by notifying Southern Cross cannabis Clinic and this practice in writing.
  9. It is my responsibility alone to ensure I comply with all laws, employment contracts, safety guidelines and sundry regarding medicinal cannabis treatment and THC/other cannabinoid levels within my body.
  10. Southern Cross Cannabis Clinic and this practice accepts no liability or claims for the dispensing, compounding or administration of medicinal cannabis products.
  11. All costs of accessing, purchasing, using and sundry of medicinal cannabis are my personal responsibility.
  12. I agree not to share, sell, lend, trade medicinal cannabis or in any way give my medicinal cannabis to any other person. I realize this is an illegal act. I also agree that my cannabis doctor and/or pharmacist may work with the police and/or government authorities to investigate any alleged misuse of my medicinal cannabis.
  13. I have been advised and understand that it is an offence under relevant State legislation for a person to drive, attempt to put in motion, or be in charge of, a motor vehicle, tram, train or vessel, while the person has delta-9-tetrahydrocannabinol present in the person’s blood or saliva. I further understand that there is no medical defence at law in these situations.
  14. I understand that I may be prescribed Provocatus medicinal cannabis products for my condition and that members of Southern Cross Cannabis Clinic have a commercial interest in these products.
  15. I agree to all Trading Terms and Conditions, all Terms and Conditions of Use, all sundry Terms and Conditions, and all Privacy Policies for Southern Cross Cannabis Clinic and this practice, and these can be viewed online anytime on the relevant entity’s webpage.
  16. If signed on behalf of a patient, I acknowledge that I accept full responsibility for medicinal cannabis use on behalf of the patient.