Dispensing Form

Dispensing Checklist

Confirm the information is correct.

That the collecting person matches the information on the medication.
1. That all information provided above is accurate.
2. That the patient’s address has not changed (record below if a recent change has occurred).
3. That no major changes to current medicines or health status have occurred (record below if a recent change has occurred).
Communicated key information:
1. It can take 1-3 months to get the dose right – everyone is different so be patient and work with eCS Clinic during the titration phase.
2. Your Patient Advocate will be in contact with you to check on your progress in the coming days.
3. If you have any questions, concerns or issues, please call eCS Clinic (03 9117 9000).
4. Cannabinoid medications can cause drowsiness, flushing of skin, a quicker heart rate, blood shot eyes – in some people, if you experience adverse effects please contact your Patient Advocate at eCS Clinic (03 9117 9000).
5. It is currently illegal to drive or operate heavy machinery if THC is detectible, and may be detectible hours after administration in saliva and longer in blood
6. Read the CMI in the parcel.

First Name

Last Name

Date of Birth

Dispensing Pharmacist's Full Name

Dispensing Pharmacy

Date medications were dispensed

If Patient's address has changed, please record this below. Otherwise, this information can be left blank.

City

State

Post Code

If significant changes to the patient's current medicines or health status have occurred, please record this below. Otherwise, the below field can be left blank.

Additional Information and Notes.

Dispensing Checklist Confirmation

I confirm I have read and completed the above Dispensing Checklist and completed the steps.

Dispensing Form

Dispensing Checklist

Contact Details

Other Pages

Our Clinics