New Patient Form - CanTx

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About Us
Plant Therapy
How it Works
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FAQs
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New Patient Form

"*" indicates required fields

Title

First Name*

Last Name*

Preferred Name

Date of Birth*

MM slash DD slash YYYY

Mobile Phone*

Email Address

Enter Email Confirm Email

Street address*

Suburb*

State*

Postal / Zip Code

Do you have a history of the following?

Allergies or sensitivity to drugs or dressings

Asthma

Diabetes

Pregnant/Breastfeeding

Psychosis

Schizophrenia/Bipolar

Hypertension

Severely impaired kidneys/liver function

Substance abuse

Current heart conditions/previous myocardial infarction/unstable angina

Organ recipient

Operations (in the last 5 years)

What is the most suitable timeslot for CanTx to contact you?

Please note, time zone is set to Melbourne. CanTx is open from 9am-5pm AEDT. We do our best to call within your preferred timeslot.

Where did you hear about the CanTx platform?

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info@cantx.com.au

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