Eligibility Form - Atlus

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Personal Details

Are you over the age of 18?*

Yes

No

Please confirm that you agree and understand that only the parent or legal guardian of the patient aged under 18 will be contacted in regards to arranging appointments and processing payments.*

I agree and understand

Register Your Eligibility

Are you suffering from a chronic condition? (a condition present for more than 3 months)*

No

Yes

Please share with us, what is your diagnosed condition?*

Have you been prescribed medication(s) for your condition?*

No

Yes

Did the medication(s) successfully control your condition or symptoms?*

No

Yes

Were you experiencing side effects on the medication(s)?*

No

Yes

Do you suffer from cardio or respiratory diseases? (heart and lung conditions)*

No

Yes

Do you have a history of psychosis or schizophrenia?*

No

Yes

Are you or have you ever been on the Opioid Treatment Program?*

No

Yes

Please be aware that further information may need to be provided to confirm your eligibility.

Are you pregnant, planning for pregnancy or breastfeeding?*

No

Yes

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Eligibility Score

Name*

First Name Last Name

Email*

Mobile Number*

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