Compassionate Access to Care Form

Little Green Pharma/Cannatrek Compassionate Program Application

For Doctors or Pharmacists:

A doctor or pharmacist may complete this application on behalf of a patient. Once the application has been reviewed, we will notify you of the outcome within five days.

Please note that the individual completing this form will be required to upload supporting documentation, including evidence of eligibility, a copy of the prescription, and Therapeutic Goods Administration (TGA) approval.

For Patients:

Patients wishing to apply should speak to their prescribing doctor or dispensing pharmacist.

Patient Details

Patient First Name: *

Patient Last Name: *

Patient Email Address: *

Patient Phone Number: *

Evidence of Eligibility

Evidence of Eligibility: *

Veteran (Provide a copy of a valid Department of Veterans’ Affairs (DVA) Veteran Card (e.g. Gold, White or Orange Card).Front-line worker (Provide a statutory declaration from the applicant’s employer confirming current frontline employment status).Government concession card (Provide a copy of a valid Australian Government concession card (e.g. Pensioner Concession Card, Health Care Card, or other eligible Commonwealth concession card).Complex medical condition and/or significant financial hardship related to treatment costs (Provide a letter of support from the treating medical practitioner outlining the clinical complexity and/or financial hardship associated with treatment).

Proof of Criteria: *

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Please upload proof of the above criteria. Multiple uploads are allowed.

Medical Practitioner Details

Doctor First Name: *

Doctor Last Name *

AHPRA Registration Number: *

Medical Practice Name *

Medical Practice Phone Number *

Clinic/Doctor Email Address *

Upload copy of prescription(s) *

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TGA approval document(s) *

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Pharmacy Details

Pharmacy Name *

Pharmacy Contact Number *

Pharmacy Email Address *

Consent and Authorisation

Full Name: *

Contact Email Address: *

Who completed this form? *

By ticking this box I consent to Cannatrek and subsidiary entities using and storing this information for the purpose of reviewing, processing and documenting the outcome of my application for the Compassionate Access to Care Program. *

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Please note that the application review process may take up to 5 business days.