Patient ENQUIRY

**IMPORTANT** Please read before proceeding Before scheduling an enquiry, please ensure you meet our eligibility criteria. Please confirm you do not: - have no history of Psychosis - have no history of Bipolar Affective Disorder - currently breastfeed or suspect you are pregnant - have a history of drug dependence and/or substance misuse If you do not meet the eligibility criteria outlined above, please contact our team separately so we can support you to find the right service based on your circumstances. Please assist us to direct your enquiry to one of our customer care consultants best suited to your personal situation, by pre-filling in the following form
I confirm I have read the eligibility and privacy statement above *
SECTION 1
Name *
Name
What is your date of birth?
What is your date of birth?
Please provide your best contact number *
Please provide your best contact number
What is your address?
What is your address?
SECTION 2
Do you have any of the following conditions? *
Have you enquired with your existing doctor/specialist about alternative treatment options? *
Please help us understand your circumstances better *
Please help us understand your circumstances better
Existing prescribed treatment for my condition has not completely resolved my symptoms
My pain/discomfort impacts my overall quality of life
I am prepared to fund my own treatment
I consent for my information to be shared with medical professionals and relevant regulatory authorities? *
Your application will be submitted to one of the Cannvaclinic team for review, you can expect to hear from us within 24 hours, please feel free to leave any additional notes that may support your enquiry below