Patient Registration Form

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Update Patient Information:

Address Information:

Emergency Contact Information:

Password Information:

Membership Pricing

  • All
  • Section 21
  • Medical

In-Shop Collection

Section 21 Member

R 600.00 /Year

Benefits

  • Access to club facilities, including lounge areas and private meeting rooms
  • Invitation to exclusive events, workshops, and social gatherings
  • 10% discount on in-store purchases of cannabis products and accessories
  • Monthly newsletter featuring updates, promotions, and educational content
  • Priority access to new strains and limited-edition products
  • Loyalty points for every purchase, redeemable for discounts and rewards
  • Access to member-only sales and promotions
  • Personalized membership card
  • Participation in member surveys to influence product selection and club activities

Delivery

Section 21 Member

R 1400.00 /Year

Benefits

  • All benefits of In-Shop Collection Members(Section 21 Member)
  • Free delivery of cannabis products within a 20km radius
  • Access to an online ordering platform with a user-friendly interface
  • Priority customer support with dedicated helpline and chat service
  • 50% discount on delivery charges beyond the 20km radius
  • Exclusive access to a curated selection of products available for delivery
  • Early access to new product releases and special delivery-only offers
  • Ability to schedule delivery times that suit your convenience
  • Real-time tracking of deliveries via mobile app
  • Seasonal gift hampers delivered to your door

Not Available in your area

Choose Plan

In-Shop Collection

Medical Member

R 800.00 /Year

Benefits

  • Access to medical consultations with licensed cannabis doctors (2 free consultations per year, additional consultations at a discounted rate)
  • Personalized cannabis treatment plans based on individual medical needs
  • 15% discount on all in-store medical cannabis products and accessories
  • Priority access to medical-grade cannabis products and specialized formulations
  • Monthly newsletter featuring medical cannabis news, updates, and educational content
  • Loyalty points for every purchase, redeemable for discounts and rewards
  • Access to member-only sales and promotions
  • Personalized membership card
  • Invitation to exclusive medical cannabis events and educational seminars
  • Access to a network of healthcare professionals and wellness experts

Delivery

Medical Member

R 2800.00 /Year

Benefits

  • All benefits of In-Shop Collection Members(Medical Member)
  • Free delivery of medical cannabis products within a 20km radius
  • Access to an online ordering platform with a user-friendly interface
  • Priority customer support with dedicated helpline and chat service
  • 50% discount on delivery charges beyond the 20km radius
  • Exclusive access to a curated selection of medical products available for delivery
  • Early access to new medical product releases and special delivery-only offers
  • Ability to schedule delivery times that suit your convenience
  • Real-time tracking of deliveries via mobile app
  • Seasonal wellness packages delivered to your door
  • Ongoing medical support and follow-up consultations as needed

Not Available in your area

Choose Plan

Promo Applied: 6 months off your subscription you only pay for subscription after 6 months

Medical Cannabis Use:

Cannabis Use History:

Medical Information:

Medical History:

History of:

Family History:

Relating to current treatment:

Current use per day or week?

Patient Declaration & Signature

Declaration

  1. 1. I am over the age of 18 years old.
  2. 2. I am not addicted to habit-forming substances, including controlled substances.
  3. 3. I am not engaged in the illegal buying, selling, or dealing of any restricted or controlled substances.
  4. 4. I understand that any information or materials provided to me are intended for legal and informational purposes only.
  5. 5. I acknowledge that any use of substances, materials, or information obtained through this channel is at my own risk, based upon the prescription from my traditional healer and I will adhere to script and all applicable laws and regulations.
  6. 6. I shall not resell any of the items received in terms of the script for medical cannabis, as it is intended for my personal medical used only.
  7. 7. I understand that this confirmation is a material representation upon which reliance is placed, and any false statements may lead to legal consequences.
  1. I hereby declare that the information provided in this questionnaire is accurate and complete to the best of my knowledge. I understand the importance of disclosing my medical history for the purpose of receiving appropriate medical cannabis recommendations.

Registration of Medicines

Section 21 Application Form

E. INFORMED CONSENT FORM

I (full names of the patient) voluntarily agree to be treated with a medication, namely African Green Mamba which is not registered in South Africa, Dr. G Zipp name of doctor, practice, hospital for (name of the disease).

I confirm that I have been fully informed and my questions answered by Dr. G Zipp (name of applicant, i.e. prescribing doctor) about my disease (for which a section 21 application is being made), its cause, severity, prognosis, available (in South Africa) registered treatment options and the reasons for the current state of my illness and the unregistered medication and application to use a medication that is not registered in S.A., and that:

  • the medication is not registered in South Africa and that this implies that the quality, effectiveness and safety of this medication have not been verified by the Medicines Control Council (MCC) of South Africa (S.A.)
  • the medication will only be supplied to, and used by and on me once specific approval has been obtained from the MCC of S.A.
  • the medication African Green Mamba (generic and trade names) is approved for the treatment of (my disease) in N/A (name of the country from which the medication is to be imported), or the medication is in an advanced stage of development [at least phase III trial] in South Africa and/or N/A (country of origin) and that its quality, effectiveness and safety are well documented and within legally and scientifically acceptable levels.
  • appropriate measures will be taken to prevent, monitor and manage the unwanted effects on me of the unregistered medication.
  • Dr. G Zipp (name of doctor) will comply with all regulations of the MCC, laws (S.A. and foreign) and conditions of approval of use of this unregistered medication/device and accordingly ensure continued availability and supply of the medication.
  • use of the unregistered medication on and by me is for managing my disease and not for medical research.
  • any information collected by Dr. G Zipp (name of applicant), his/her employer, successor or any other person other than the MCC or its legal representative, may be used for research purposes upon receipt of specific written separate informed consent from me, my guardian or person responsible for my affairs after my death.
  • I will be free to stop using the medication at any time and that I will inform my (treating) doctor accordingly.

Full Names of patient/guardian:

Signature of patient/guardian: Date: 2025-12-02

Name of doctor (applicant):

Signature of doctor: Date: 2025-12-02

Name of witness:

Signature of witness: Date: 2025-12-02

6.12_Section_21_Application_Form_Feb04_v1_2     Jan 2013     Page 9 of 11


on 2025
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