[DEV] Mediflora Consent Form - Feb 2026

Consent & Medical Intake Form. Mandatory before initial consultation. Attach to HubSpot record; send to admin for Care Effect Upload.

Phone

This field is for validation purposes and should be left unchanged.

Mediflora Consent Form

Thank you for choosing Mediflora Organic Health Clinic.

To provide safe, personalised care, we need some important information before your appointment.

This Consent & Medical Intake Form is mandatory and must be completed prior to the time of your initial consultation.

For telehealth / remote appointments:
If this form is not completed before your booked time, your appointment may be redirected to a nurse-led initial review so we can gather the required information before you see a doctor. If nursing staff are not available, your appointment may need to be rescheduled.

For face-to-face appointments:
Not completing this form in advance may delay your appointment while these details are obtained.

By completing this form, you help us understand your medical history, current treatments, preferences and goals, and you provide consent for us to deliver care in line with our clinical and privacy policies.

Please read each section carefully and tick to confirm your understanding. Completing this consent section is required before you can see a doctor at Mediflora Organic Health Clinic.

Bookings and Communication

By continuing with my booking, I understand and agree that:

- I may be asked to provide my credit card details to secure appointments and to pay consultation fees. If I cancel, reschedule or do not attend an appointment with less than 24 hours' notice, I may be charged a fee up to the full value of the booked appointment. Appointment reminders are a courtesy only; not receiving a reminder does not remove my responsibility to attend or cancel within the required timeframe.
- Mediflora may contact me about my care and bookings via SMS, phone and email (for example, reminders, links to forms, brief result notifications and follow-up instructions). I understand these methods are not emergency services and may not be monitored at all times. For urgent or life-threatening issues I will call 000 or attend an emergency department.
- I understand that some electronic messages may contain limited health information and, while Mediflora takes reasonable steps to protect my privacy, electronic communication can carry some security risk. I consent to being contacted in this way.
- I am responsible for ensuring my contact details (mobile number, email address and postal address) are accurate and kept up to date. If my details are incorrect or I do not update them, I understand that I may miss important communications and that Mediflora is not responsible for any consequences arising from this.
- I understand that completing required intake and consent forms before my appointment is a condition of booking. For remote appointments, if these forms are not completed in time, my booking may be converted to an initial nursing review (where available) so information can be collected before I see a doctor, or my appointment may be rescheduled.
- I understand that Mediflora may need to change the time of my appointment, or the clinician I see, due to clinical, staffing or operational reasons. While reasonable efforts will be made to accommodate my preferences, no particular clinician or appointment time can be guaranteed.

Bookings and Communication – Consent(Required)

I have read and understand the above bookings and communication terms, and I agree to proceed under these conditions.

Unapproved natural therapies – Acknowledgement of risks

By consenting to treatment with natural therapies at Mediflora, I understand and agree that:

- The natural therapies (including medicinal cannabis) that may be prescribed or recommended to me at Mediflora can include unapproved therapeutic goods under the Therapeutic Goods Act 1989 (Cth). This includes products such as certain plant-based medicines, which have not been evaluated by the TGA in the same way as fully registered medicines for safety, quality or effectiveness, and are accessed via special pathways (e.g. Special Access Scheme or Authorised Prescriber).
- The use of these unapproved natural therapies is considered an emerging or experimental treatment approach, and the clinical evidence is still developing. Evidence may be limited or uncertain for my specific condition or symptoms, and no benefit can be guaranteed.
- The long-term safety and effects of ongoing treatment with these therapies are not fully known, especially with higher doses or prolonged use, and there may be risks or side effects that are not yet well understood.
- I may experience unwanted side effects, including but not limited to: sedation or drowsiness; fatigue; reduced concentration or slower reaction times; dry mouth; nausea; vomiting; diarrhoea; dizziness; light-headedness; balance problems or increased risk of falls; changes in thinking, memory, perception or coordination; and psychological effects such as anxiety, agitation, paranoia, mood changes or hallucinations.
- These therapies can worsen certain mental health conditions, including but not limited to psychosis, schizophrenia, bipolar disorder/mania and severe anxiety, particularly in people with a current or past history of these conditions or a strong family history. If I have, or develop, any of these problems, I will tell my clinician promptly.
- Regular use of some natural therapies can lead to tolerance (needing more to achieve the same effect) and withdrawal symptoms (such as irritability, sleep disturbance, anxiety, reduced appetite or mood changes) if treatment is stopped suddenly. My clinician may recommend a gradual dose reduction if treatment needs to be reduced or ceased.
- Alcohol, sedatives, opioids and other intoxicating or recreational substances may add to the sedating and impairing effects of these therapies and increase my risk of harm. I will follow my clinician's advice about using these substances together and seek clarification if I am unsure.
- These therapies may interact with other prescribed and over-the-counter medicines and supplements. I agree to tell my clinician about all medicines, supplements and substances I am using, and to inform them before starting, stopping or changing any important medication while being treated with natural therapies through Mediflora.
- I will follow my clinician's dosing instructions carefully and will not increase the dose, frequency, or add additional products on my own without discussing it first (except in an emergency where I am advised to seek urgent care). I will promptly report any concerning or unexpected side effects to Mediflora or, in an emergency, seek urgent medical help.
- I understand that natural therapies used at Mediflora are generally intended to support or complement standard medical care, and that I should not stop any important existing medicines or treatments without medical advice, even if I commence treatment with natural therapies.

Unapproved natural therapies – Consent(Required)

I have read and understood the information above about unapproved natural therapies, their potential risks and limitations of evidence, and I consent to my clinician considering and/or prescribing these treatments where clinically appropriate.

Prescribing, Follow Up and Regulatory requirements

By proceeding with treatment at Mediflora, I understand and agree that:

- My clinician will discuss the nature of any proposed treatment, including potential benefits, risks and alternatives, and there is no guarantee that any natural therapy (including medicinal cannabis) will improve my condition. Treatment may be changed or stopped if it is not effective, not tolerated, or not clinically appropriate.
- Ongoing prescribing is conditional on regular reviews (telehealth or in-person), monitoring as requested (e.g. pathology tests, questionnaires), and my reasonable adherence to the agreed treatment plan.
- My clinician may decline to start, continue, or increase natural therapies (including medicinal cannabis) if this is considered clinically inappropriate, unsafe, inconsistent with guidelines or regulations, or if there are concerns about misuse, diversion, or repeated non-attendance/breaches of clinic policies.
- Prescribing must comply with Australian federal and state/territory laws. Depending on where I live, there may be extra approvals, documentation or limits on certain products or doses. These regulatory requirements are set by government authorities and may cause delays that are outside the control of Mediflora or its clinicians.
- For some higher-risk or higher-dose treatment plans, my clinician may require supporting information from my GP or specialist and may need to submit additional applications to regulators before prescribing. Approval is not guaranteed.
- Mediflora aims to be product-agnostic, and prescribing decisions must be based primarily on my clinical needs, safety, evidence and regulatory requirements.
- From time to time, Mediflora or individual clinicians may work with, receive education or consulting fees from, or hold shares or other interests in companies involved in natural therapies or pharmaceutical products. Any material conflict of interest relevant to my care will be disclosed on request.
- Mediflora may recommend or work closely with certain partner pharmacies to help ensure product availability and timely dispensing; however, I understand I am generally free to choose a different pharmacy, and Mediflora does not receive commissions based on the volume of prescriptions filled for me.
- During my consultations, Mediflora may use secure digital tools, including audio transcription and AI-assisted note-taking, to help document my history and treatment plan accurately. These tools are used only to support clinical documentation, do not replace my clinician's judgement, and are used in line with Mediflora's privacy and data-security policies.

Prescribing and regulatory – Consent(Required)

I have read and understood the information above about prescribing, follow-up and regulatory requirements, and I agree to participate in regular review and monitoring as a condition of ongoing treatment.

Dosing, Safe Use, Storage, Travel and Driving Obligations

By consenting to treatment at Mediflora, I understand and agree that:

- I will follow the principle of "start low, go slow" with any prescribed natural therapies and will not increase the dose, change how often I take it, or add other similar products (including non-prescribed cannabis or other plant products) without medical advice, except in an emergency where I am advised to seek urgent care.
- If I feel dizzy, confused, unusually sedated, unwell or otherwise unsafe after using a prescribed product, I will stop using it and seek medical advice promptly, and in an emergency I will seek urgent care (e.g. call 000 or attend an emergency department).
- I will not share my prescribed products with anyone else, including family or friends, and I understand that sharing, selling or giving away prescribed medicines is unsafe and may be illegal.
- I understand my medication must remain in its original packaging with the pharmacy label intact, and that I should carry a copy of my prescription or a current medication summary when transporting it.
- I understand that driving, riding a bike or operating vehicles or machinery while impaired by any medicine is unsafe and may be illegal. Products that contain THC can impair my attention, judgement and reaction time. In many Australian states and territories, it is an offence to drive with any detectable THC in my system, even if I have a prescription, and a prescription is not a legal defence to roadside drug testing. It is my responsibility to know and comply with the laws of the state or territory in which I am driving. I understand it is my responsibility to comply with all driving and workplace safety laws and policies, including any rules that apply to safety-sensitive duties. Mediflora and its clinical staff are not liable for any legal, employment or licensing consequences that may result from my use of prescribed products.
- I understand that prescribed products, particularly those classified as Schedule 8 (S8) or otherwise controlled medicines and/or containing THC, must be stored securely: in their original packaging, in a locked container, cabinet or other safe place, and out of reach of children and unauthorised persons. I agree to take full responsibility for the safe storage of my prescribed products. If my medication is lost or stolen, I will notify Mediflora and, if appropriate, the police.
- When travelling within Australia with prescribed products, I will keep them in their original packaging with the pharmacy label attached and carry a copy of my current prescription or medication summary. I understand that some states or territories may have additional requirements or restrictions.
- I acknowledge that possession or transport of medicinal cannabis or similar products outside Australia, or into some countries, may be illegal, even with a prescription. I understand that it is my responsibility to check the laws of any country or jurisdiction I travel to, and that Mediflora and its clinical staff are not responsible for any legal or customs consequences arising from travel with these products.

Dosing, safe use, storage, travel and driving – Consent(Required)

I have read and understood the information above about dosing, safe use, storage, travel and driving, and I agree to follow these instructions and legal obligations while using prescribed products.

Costs, Legal Responsibilities and Regulatory compliance

By continuing with treatment at Mediflora, I understand and agree that:

- The cost of consultations, natural therapies and any prescribed products (including plant-based or cannabinoid medicines) is my responsibility. These products are not subsidised under the Pharmaceutical Benefits Scheme (PBS) and prices may change over time. Any pharmacy dispensing fees, delivery charges or other costs are separate to Mediflora's consultation fees.
- Any private health insurance or other rebates are a matter between me and the relevant fund or organisation. Mediflora cannot guarantee that any part of my treatment will be reimbursed.
- It is illegal to share, sell, lend, transfer or give away any prescribed medicines to another person. I will not allow others to use my prescribed products, and I understand that doing so may be a criminal offence.
- If there is evidence or reasonable suspicion of misuse, diversion, forgery of prescriptions, unsafe use or illegal supply of prescribed products, my healthcare provider, pharmacy or Mediflora may be required to cooperate with regulators or law enforcement authorities and to limit, change or stop prescribing in order to comply with the law.
- I agree to provide complete and accurate information about my medical history, current medications, other treatments and substance use, and to update Mediflora if these change. I understand that failure to disclose relevant information may increase my risk of harm, may affect my eligibility for treatment, and may lead to review or discontinuation of prescribing or care.
- I understand that my treatment may be subject to regulatory oversight, including audits or checks by health departments, the TGA, Ahpra or other authorities, and that Mediflora and its clinicians may be required by law to share information or reports about my treatment or prescribing in order to meet their legal and professional obligations.
- I understand that I am personally responsible for complying with all applicable laws and regulations, including those relating to medicines, driving, workplace safety and possession of controlled substances, and that Mediflora and its clinicians are not liable for any fines, charges, employment consequences or other legal outcomes that arise from my actions.

Costs and legal – Consent(Required)

I have read and understood the information above about costs, legal responsibilities and compliance, and I agree to meet these obligations while receiving care at Mediflora.

Data, Outcomes, Research and Consent

I understand that Mediflora collects information about my health, diagnoses, treatments, symptom scores and responses to treatment as part of providing clinical care.

I understand that this information may also be used by Mediflora for: internal quality improvement and service planning; clinical audit and safety monitoring; education and training of health professionals; research and outcomes reporting, including possible publication of de-identified results.

I understand that: wherever reasonably possible, information used for these purposes will be de-identified; results are generally reported in grouped or summary form, and individual patients are not personally identified in any report, presentation or publication without specific written consent; Mediflora may be required by law or professional standards to disclose information to regulators or other bodies.

By receiving care at Mediflora, I consent to the use of my health information in these ways, in addition to its use for my own clinical care and as required by law.

Data and research – Consent(Required)

I consent to Mediflora collecting and using de-identified information from my records for quality improvement, clinical audit, education and research, in accordance with privacy laws and clinic policies.

Reproductive Safety and Opiate Replacement

By continuing with treatment at Mediflora, I understand and agree that:

- Some of the natural therapies used at Mediflora, particularly those that act on the endocannabinoid system, are not recommended during pregnancy or breastfeeding because of potential risks to the developing baby or infant.
- In most cases, these therapies will not be initiated or continued during pregnancy or breastfeeding unless there are exceptional circumstances and the potential benefits are considered to clearly outweigh the risks, in consultation with appropriate specialists.
- I confirm that I am not currently pregnant or breastfeeding, and I agree to inform my clinician immediately if I become pregnant, suspect I may be pregnant, start trying to conceive, or commence breastfeeding while under Mediflora's care.
- I understand that if I become pregnant or start breastfeeding, my treatment may need to be changed, paused or stopped, and that I should not rely on natural therapies alone for the health of myself or my baby.
- If I am someone who could become pregnant, I understand it is strongly recommended that I use a reliable form of contraception while using these therapies, and that I discuss any plans for pregnancy with my clinician before trying to conceive.
- I understand that therapies which have sedating or CNS-depressant effects are not recommended to be used concurrently with opiate replacement (opioid agonist) therapies such as methadone or buprenorphine, except with very careful specialist oversight, because of increased risks including oversedation, respiratory depression, overdose and impaired function.
- I confirm that I am not currently on an opiate replacement / opioid agonist treatment program (for example methadone, buprenorphine, Suboxone®, or similar), and I agree to inform my clinician immediately if I start or re-start such a program while under Mediflora's care.
- I understand that if I am on, or later commence, an opiate replacement program, my clinician may decide that these natural therapies are not appropriate, or may need to change or cease treatment, and may recommend shared care or review with my opioid treatment prescriber.

Reproductive safety and opiate replacement – Consent(Required)

I have read and understood the information above about reproductive safety and opiate replacement therapies, and I confirm that the information I have provided about pregnancy, breastfeeding and opioid treatment status is true and that I will inform my clinician immediately if this changes.

Informed Consent

By signing below, I confirm that:

- I have read and understood all of the information provided in this consent and intake form, including the sections on unapproved natural therapies, prescribing and follow-up, dosing and safe use, storage, travel and driving, costs and legal responsibilities, and reproductive safety and opiate replacement.
- I have had the opportunity to ask questions about my condition, proposed treatments, potential benefits, risks, side effects and alternatives, and any questions I have asked have been answered to my satisfaction.
- I understand that no specific outcome or improvement can be guaranteed, and that my treatment may be adjusted, paused or stopped if it is not effective, not tolerated, clinically inappropriate or inconsistent with legal or regulatory requirements.
- I understand that I may seek a second opinion or discuss alternative options with another healthcare provider at any time.
- I understand that I can withdraw my consent to treatment at any time, noting that this may affect ongoing prescribing or access to certain therapies, but does not limit my right to receive appropriate emergency or acute care.
- I consent to Mediflora's clinicians providing assessment, treatment and monitoring using the approaches described in this form, including the use of natural therapies (and, where appropriate, medicinal cannabis) in line with current regulations and clinical judgement.

Final informed consent(Required)

I have read and understood all of the information in this consent form and I consent to Mediflora's clinicians providing assessment, treatment and monitoring as described.

[DEV] Mediflora Consent Form - Feb 2026

Locations

Talk to a nurse.