SECTION A: Personal Details

Title *

First Name/s *

Surname *

Preferred Name *

Date of Birth *

Phone Number *

Email Address *

Home Address *

Address line 1 *Address line 2

City *

State *

Postcode *

Occupation *

Medicare Card No

Ref No

Expiry

Do you hold any of the following cards?

Pension Concession CardHealth Care CardCommonwealth Seniors Health Care Card

Card No

Expiry Date

DVA Card No

DVA Expiry

Type

WhiteGoldOrange

SECTION B: Emergency Contact Information

First and Last Name of who we can contact in the event of an emergency

Contact Number

Relationship to you

SECTION C: Cultural Background

SECTION D: Regular General Practitioner

Doctor/Practice Name

Practice Address

Practice Contact Number

SECTION E: Medical History

Are you currently taking any medications? If yes, please specify. *

Current / Past medical and mental health history *

Allergies or intolerances

Are you currently pregnant or breastfeeding? (Support with alternative strategies may be appropriate) *

YesNoN/A

Social responsibilities (i.e. children, carer)

Has your smoking or vaping habit persisted for more than 3 months? *

YesNo

Do smoke cigarettes, use a vape device or both? *

Previous smoking cessation attempts (include methods such as nicotine patches, gum, cold turkey, other medications): *

If known, please share reasons for relapse or unsuccessful cessation attempts (e.g., withdrawal symptoms, ineffective, side effects; please list any specific side effects experienced): *

Our doctors can discuss vaping devices as part of a quitting regime where previous strategies have failed. Which types of vaping devices would you like to discuss with our doctors *

Closed-pod medical vapesE-liquid nicotine salt open medical vapesE-liquid nicotine open medical vapesDon't know None - I would prefer to discuss other methods

Would you like additional referrals to other services / specialists?

QUIT Line Referral - FREE 24/7 phone support 13 7848Psychologists for counselling or behavioural supportOptimal Wellness Pathology TestingIntegrative Medicine Practitioner (to support conditions contributing to smoking)Dietitian or Nutritionist (to manage weight concerns related to quitting smoking)Exercise Physiologist (to develop a physical activity plan that supports health improvement)Pulmonologist (for lung health assessment)Cardiologist (for heart health assessment)None

Do you use recreational drugs?

NoI have previously usedI currently useI prefer not to say

SECTION F: Consent

I consent to a Releaf Concierge member contacting me regarding my experience at the Releaf Clinic, including receiving my smoking cessation products from the Releaf Dispensary. I consent to Releaf Concierge, Clinic and Dispensary Team Members collaborating to enhance my care and being contacted for feedback regarding my care experience. *

YesNo

I consent to receive SMS reminders regarding future appointments *

YesNo

I consent to email correspondence from Releaf Clinics & Dispensaries *

YesNo

The above information is true to the best of my knowledge. I consent for the above information to be used for administrative or billing purposes or to comply with legislative or regulatory requirements. I understand the Clinic’s aim is to protect the privacy and secure storage of my personal information.

Signature *

Draw signature|Type signatureClear

Date