Doctor Referral Form

Full name:

DOB:

Phone number:

Address:

Email:

Prescriber name

Prescriber address

Prescriber contact number

The patient has been provided with a current health summary to present to our clinic.

The patient has trialed, or has had a discussion regarding, all conventional or registered treatment options relevant to the referral indication.

I hereby refer the above-named patient to Kush Clinics, in partnership with Summit Pharmacy, for a clinical assessment to determine the suitability of medicinal cannabis therapy.

Alternative Therapy Services

Kush Clinics

Summit Pharmacy Sunshine Coast

Summit Pharmacy Brisbane

Patients

Doctors

Legal

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