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• Doctor
• Sponsor

Applicant Details

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AHPRA No *

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Application Details

I certify that I *

• Have applied for Authorised Prescriber approval from another Australian HREC (not ANZCCP) within the last 12 months
• Have not applied for Authorised Prescriber approval from another Australian HREC (not ANZCCP) within the last 12 months

Where an applicant has been refused approval for Authorised Prescriber by an Australian HREC or the TGA within the last 12 months, please detail why approval was denied. *

Site(s) at which the unapproved good will be prescribed (list all addresses) *

How will risks associated with the use of the unapproved good by managed? This should address: a. Process of obtaining informed consent from patients b. Monitoring and reporting that will be undertaken (include details of interval and duration of monitoring) c. Process of investigating and reporting adverse events *

Scheduled Products & Indications To Apply For

Approval is being sought for the following scheduled medicinal cannabis products & indications.

Additional Products (Category and Dosage) *

Additional Indications (if applicable)

Clinical justification for the use of the unapproved goods *There is sufficient evidence to justify the use of the above unapproved goods for patients who suffer from symptoms secondary to the above indications, when those symptoms are serious enough to affect their function and/or quality of life, when approved treatments were unsuccessful, caused intolerable side effects or were otherwise inappropriate and where no contraindications for the use of the unapproved goods exist. In these cases, the potential benefit of using the unapproved good outweighs any potential harm.

Patient population

• Adults
• Paediatric – under 18y/o (paediatricians only)

Additional Required Documents

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Disclosure

I certify that I *

• Do not have a commercial interest in any of the products for which I am applying
• Do have a commercial interest in one or more of the products for which I am applying

Details of my commercial interests are as follows: *

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