Patient Questionnaire - Greenhaven Doctors

Please answer the form to the best of your knowledge, this will help us determine the best way to assist you with your enquiries. Please push submit at the end once you have finished.

Do you have a chronic condition (3 months or longer)?

No, I don't experience any chronic condition or pain Yes, I am currently being treated by a doctor Yes, I am seeing an allied healthcare professional Yes, I am self-medicating or self-researched attempts

Other treatments for your medical condition(s)?

I’ve used prescription medication I've used natural alternatives (e.g. physiotherapy, psychological therapy, etc) I haven't being treated for my medical condition I've used other treatments I'm not treating my condition because I'm opposed to conventional medication

With your previous treatment:

Your condition is being treated Did not provide relief of symptoms from your medical condition Caused unnecessary and unwanted side effects or impact Attempted self-treating and access of plant medicine

Are you currently pregnant or planning to become pregnant?

Yes No

Do you have a history of experiencing psychosis?

Yes No

Have you discussed with your regular GP about your medical conditions?

Yes No

Signature Acknowledgment

I consent to receiving this from Greenhaven Doctors

Prior to any services provided to minor or dependent patients (if applicable), Greenhaven Doctors will require the authorised parent / guardian to provide relevant proof of ID and proof of guardianship

Acknowledgement Date

Payment Method

Pay Via Bank Pay Via Card

Select payment Amount

Initial Consultation($79 + 2.9% extra on Visa/MasterCard transactions) Returning Patient Consultation($49+ 2.9% extra on Visa/MasterCard transactions)

Select payment Amount

Initial Consultation($79) Returning Patient Consultation($49)

Initial Consultation : $79
Returning Patient Consultation: $49

Please arrange the payment via bank transfer using the details provided below.

Bank: CBA
Account Name: Dri Mason Pty Ltd
BSB: 063020
Account Number 10667128
Reference: Your Full Name

Please send payment screenshot/receipt to booking@ghdoctors.com.au or text message to 0459 502 030.

Please note only confirmed payments will ensure the appointment booked will be completed. If the payment confirmation isn’t received before the consultation time, the appointment will be automatically cancelled.

Please answer the form to the best of your knowledge, this will help us determine the best way to assist you with your enquiries. Please push submit at the end once you have finished.

Do you have a chronic condition (3 months or longer)?

Other treatments for your medical condition(s)?

With your previous treatment:

Are you currently pregnant or planning to become pregnant?

Yes No

Do you have a history of experiencing psychosis?

Yes No

Have you discuss with your regular GP about your medical conditions?

Yes No

Signature Acknowledgment

I consent to receiving this from Greenhaven Doctors

Acknowledgement Date

Pay Via Bank

Initial Consultation($79) Returning Patient Consultation($49)

Initial Consultation : $79
Returning Patient Consultation: $49

Please arrange the payment via bank transfer using the details provided below.

Bank: CBA
Account Name: Dri Mason Pty Ltd
BSB: 063020
Account Number 10667128
Reference: Your Full Name

Please send payment screenshot/receipt to booking@ghdoctors.com.au or text message to 0459 502 030.

Please note only confirmed payments will ensure the appointment booked will be completed. If the payment confirmation isn’t received before the consultation time, the appointment will be automatically cancelled.

Pay Via Card

Initial Consultation($79) Returning Patient Consultation($49)

Patient Questionnaire - Greenhaven Doctors

Please answer the form to the best of your knowledge, this will help us determine the best way to assist you with your enquiries. Please push submit at the end once you have finished.

Do you have a chronic condition (3 months or longer)?

Other treatments for your medical condition(s)?

With your previous treatment:

Are you currently pregnant or planning to become pregnant?

Yes No

Do you have a history of experiencing psychosis?

Yes No

Have you discuss with your regular GP about your medical conditions?

Yes No

Signature Acknowledgment

I consent to receiving this from Greenhaven Doctors

Acknowledgement Date