Authorised Prescriber New Application & Renewal Form

Please ensure you have made payment prior to the next HREC submission cut off date.

Non-payment will result in your application not being reviewed at the next HREC meeting.

Are you a doctor or a sponsor submitting this form on behalf of a doctor?
Do you wish to create an account on this site
New or Renewal of Application?

Applicant (Doctor) Details

Name
Address

Application Details

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(NOTE: We will not start reviewing your application until the applicant has completed the AP Exam with a passing mark of 80% and sent their certificate to [email protected])
You must address all 3 criteria:
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.
Schedule 4 products (Dosage form – Route of administration)
Schedule 8 products (Dosage form – Route of administration)
Indications List

Additional Indications (Optional)

Selected Value: 0
Patient population

New AP appplication

  • 4 x TGA SAS B Approval Letters (At least 2 Schedule 4 (Category 1) and 2 Schedule 8 (Category 2-5), two of which should be for Dried Herb (if you wish to include it in your application)
  • Patient Informed Consent Form – Using the ANZCCP Consent form template
  • ANZCCP AP Course Test Certificate
  • Evidence of additional professional education – if applicable
For Renewal of Application.

Please ensure you upload with your application:

  • Previous HREC AP approval letter
  • Previous HREC AP amendment letter(s) *
  • TGA 6 monthly reports for previous HREC approval period
  • Patient Informed Consent Form – Using the ANZCCP Consent form template
  • Evidence of additional professional education (if available) 

Additional Required Documents

Patient Consent Form

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TGA Documents

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HREC Documents

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Other Evidence

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Disclosure

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