Section 21 Patient Intake Form SECTION 21 APPLICATION Patient Intake and Informed Consent Treating practitioner Dr Petrus F. Serfontein Section 21 overview SAHPRA may permit access to unregistered medicines through a Section 21 application in specific exceptional circumstances. Medicinal cannabis may only be supplied on a legitimate prescription and under medical supervision. Supporting documents required Notification of payment for SAHPRA and the practitioner Clear copy of ID Photo with white background similar to an ID photo Proof of payment SAHPRA Proof of payment practitioner Copy of ID ID style photo Payment details SAHPRA Bank ABSA Account type Cheque or Current Branch code 632005 Account number 4059392080 Amount R400 Reference Name or ID number Email proof of payment to martie@cbdfullspec.co.za Dr Petrus F. Serfontein Bank Capitec Account type Savings Branch code 210523 Account number 2190632591 Amount R350 Reference Name or ID number Email proof of payment to martie@cbdfullspec.co.za Contact number 083 388 5331 Particulars of patient Title Select Mr Ms Mrs Dr Prof Full names Surname ID number Age Gender Weight kg Height cm Occupation Email Telephone Cellular number available on WhatsApp video call Residential address full details Work address full details Diagnosis and current treatment Diagnosis with severity staging and prognosis where applicable Current treatment regimen for the diagnosis include medicinal surgical and other treatment Other conditions and current treatment if applicable Cannabis use Do you smoke cannabis Yes No Do you use cannabis in any other form Yes No If yes specify Informed consent By completing this section you confirm that you have been informed about your disease the available registered treatment options the unregistered medication and the application to use it as permitted under Section 21. You acknowledge the following The medication is not registered in South Africa. Quality effectiveness and safety have not been verified by SAHPRA Supply and use will only occur after specific approval from SAHPRA Appropriate measures will be taken to prevent monitor and manage unwanted effects Use is for management of disease and not for medical research You may stop the medication at any time and will inform the treating doctor Full names of patient or guardian Date Signature of patient or guardian Clear Use your mouse or finger to sign Privacy notice Information provided will be used for the purpose of a Section 21 application patient care and related administrative requirements. Do not submit this form online unless you have a secured submission method. If unsure submit in person or via a verified clinic portal Submit Print
