Registration

Step 1 of 39

Let's Get Started

Name*(Required)

First Name* Surname*

Email*(Required)

Enter Email Confirm Email

Signed up before? Log in here

Section 1 Of 3

This section is designed to obtain your informed consent to treatment and to screen out those who are unsuitable to proceed

Are you the patient?*(Required)

Yes

Do you reside in Australia?*(Required)

Yes

Are you 18 years or older?*(Required)

Yes

Do you confirm that you are NOT currently pregnant or breastfeeding?*(Required)

Yes

Do you acknowledge that using any prescription medication comes with potential side effects and adverse events?*(Required)

Yes

Do you agree to report all side effects and adverse events to Hellomello as soon as possible?*(Required)

Yes

Do you agree to stop medication immediately and seek urgent medical advice if any major or concerning side effects or adverse events occur?*(Required)

Yes

Do you confirm that you do NOT have any of the following medical conditions:*(Required)

Abnormal Heart Rhythm, Cardiopulmonary or Heart Disease, Liver Disease, a known or suspected history of psychotic disorders or history of psychotic episodes.

Yes

Do you confirm that you do NOT have any history of drug dependence/abuse to the following:*(Required)

Opiods, Amphetamines, MDMA, other illicit substances

Yes

Do you acknowledge that any medication prescribed via Hellomello is for yourself only?*(Required)

Yes

Do you acknowledge that there are driving restrictions when consuming products that contain Tetrahydrocannabinol (THC)?*(Required)

Yes

Do you have a chronic condition, diagnosed by a medical professional, that has lasted for 3+ months AND have you trialled medications or other treatments for your condition?*(Required)

Yes

Select the reason(s) you are seeking assistance today with Hellomello for your presenting medical problem(s)*:(Required)

Other medications or treatments do not work for me

Other medications or treatments were deemed unsuitable for me

Other medications or treatments have caused side effects or adverse effects

Wanting to change healthcare providers

Section 2 Of 3

This section asks for your personal information

Date of Birth*(Required)

Day

Month

Year

Gender*(Required)

Male

Female

Other

Weight (kg)*(Required)

Please enter a number from 0 to 200.

Height (cm)*(Required)

Please enter a number from 0 to 230.

Mobile Number*(Required)

Landline

Medicare Number*(Required)

Medicare Individual reference number*(Required)

Medicare Expiry Date*(Required)

Postal Address*(Required)

We will send your prescription medication to this address

Street Address Suburb State Postcode Country

Section 3 Of 3

Almost there! You are up to the final section where we ask about your medical history

What is your presenting medical problem(s)?*(Required)

Abnormal blood pressure - high or low

Chemotherapy - Induced nausea and vomiting

Fibromylagia or widespread pain

Pain - Cancer related pain

Anorexia

Coeliac Disease

Insomia or sleep disturbances

Pain - Chronic pain (limbs, spine or organs)

Eating Disorder (e.g Anorexia, Bulimia, Binge Eating)

Colitis

Kidney disease / Renal Failure

Pain - Neuropathic pain

Asthma

Dementia

Bipolar Disorder (BPAD)

Personality Disorder (Eg. BPD, EUPD)

Schizophrenia

Schizoaffective Disorder

Attention-deficit/hyperactivity disorder (ADHD)

Post Traumatic Stress Disorder (PTSD)

Complex Post Traumatic Stress Disorder (CPTSD)

Inflammatory Bowel Disease (IBD)

Palliative Care

Autism Spectrum Disorder (AS)

Depression

Leg Cramps

Irritable Bowel Syndrome (IBS) (incl. Crohns Disease, Ulcerative Colitis)

Balance problems

Endometriosis

Migraines/Headaches

Parkinsons Disease

Cancer

Epilepsy

Multiple Sclerosis (M.S)

Psoriasis

Spasticity from neurological conditions

Weight management problems

Other

Please state the name of your presenting medical problem(s)*(Required)

Describe your problem in more detail*(Required)

It is important to give a complete and accurate description of your presenting medical problem. Failure to do so may cause delays and impact your eligibility for treatment.

Please provide details on any medical conditions known within your Family e.g. Heart Disease, Diabetes (optional)

Are you currently taking medication for your presenting complaint or any medication in general?*(Required)

Including prescribed medication or supplements/vitamins

Yes

Please list ALL medications or supplements/vitamins you are currently taking*(Required)

It is important to list exactly what you are taking to treat your presenting complaint. Failure to do will cause delays and may impact your eligibility for treatment. Please also add any medication you are taking in general.

Please list ALL medications or supplements/vitamins you have previously taken for your presenting complaint AND any medication you have taken in general?*(Required)

It is important to list exactly what you have previously taken to treat your presenting complaint. Failure to do so will cause delays and may impact your eligibility for treatment.

Do you have any allergies or sensitivites?*(Required)

Yes

Please list any allergies or sensitivities here*(Required)

Please select any alternative therapies you have tried

Acupuncture

Aromatherapy

Chiropractic

Diet and nutrition

Herbal medicine

Hypnotherapy

Massage therapy

Meditation

Naturopathy

Reiki

Tai chi

Chinese Medicine

Yoga

Meditation

Supplements

Light Exercise

Music therapy

Kratom

Alcohol intake (glasses per week)*(Required)

1-3

4-7

Are you a smoker? (number per day)*(Required)

1-3

4-7

PRIMARY CARE

Please provide the details of your medical or health practitioner where you have undergone treatment for your presenting complaint

Practitioner/Clinic Name*(Required)

Practitioner/Clinic Email

Phone

What is your experience with cannabis?*(Required)

I have never used cannabis

I have used cannabis previously

I occasionally use cannabis

I use cannabis often

I have been prescribed medicinal cannabis in the last 12 months

Please provide the details of your prescriber or clinic

Prescriber / Clinic Name*(Required)

Email*(Required)

Please state the medication you have been prescribed*(Required)

Declaration

Declaration:(Required)

I verify that I have honestly and accurately answered all questions to the best of my understanding. I hereby grant consent for Hellomello to review My Health Record, arrange any bulk billing or Medicare rebates for professional services on my behalf, employ my information solely for the purpose of assisting my treatment and consent to being contacted by healthcare professionals and staff members of Hellomello for reminders and assistance. If deemed necessary, I am willing to facilitate the transfer of my medical records between my primary care providers and the clinical team at Hellomello. *(Required)