Compassionate Access to Care Form

Application Form
Compassionate Access to Care Program

Please complete this application to assess eligibility for the Compassionate Access to Care Program. Once the application is reviewed, both the Patient and Doctor will be informed of the outcome.

Patient details

First name *

Last name *

Patient email address *

Patient phone number *

Qualifying criteria *

Returned serviceperson or veteran (upload a picture of the patient's eligible veteran card)Front-line worker (upload a statutory declaration letter from the patient's employer)Government concession card (upload a picture of pension, healthcare, or other card)Complex medical condition and/or significant financial burden related to the cost of treatment (a letter of support from the treating doctor)

Proof of Criteria. *

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

Treating doctor details

Doctor first name *

Doctor last name *

Medical practice name *

Medical practice phone number *

Treating doctor or clinic email address *

Medication details

Name of medication(s) *

Upload copy of prescription(s) *

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TGA approval document(s) *

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Consent and Authorisation

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. *

Save and Complete Later

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