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

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

Diagnosis and current treatment

Cannabis use

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
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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

For queries email martie@cbdfullspec.co.za