{"id":2044,"date":"2025-03-13T19:00:09","date_gmt":"2025-03-13T17:00:09","guid":{"rendered":"https:\/\/rooftop420.co.za\/?page_id=2044"},"modified":"2025-03-13T20:25:41","modified_gmt":"2025-03-13T18:25:41","slug":"section-21","status":"publish","type":"page","link":"https:\/\/rooftop420.co.za\/?page_id=2044","title":{"rendered":"Section 21 Form"},"content":{"rendered":"<div class=\"forminator-ui forminator-custom-form forminator-custom-form-2040 forminator-design--flat  forminator_ajax\" data-forminator-render=\"0\" data-form=\"forminator-module-2040\" data-uid=\"6ac40d0896709\"><br\/><\/div><form\r\n\t\t\t\tid=\"forminator-module-2040\"\r\n\t\t\t\tclass=\"forminator-ui forminator-custom-form forminator-custom-form-2040 forminator-design--flat  forminator_ajax\"\r\n\t\t\t\tmethod=\"post\"\r\n\t\t\t\tdata-forminator-render=\"0\"\r\n\t\t\t\tdata-form-id=\"2040\"\r\n\t\t\t\tenctype=\"multipart\/form-data\" data-color-option=\"theme\" data-design=\"flat\" data-grid=\"open\" style=\"display: none;\"\r\n\t\t\t\tdata-uid=\"6ac40d0896709\"\r\n\t\t\t><div role=\"alert\" aria-live=\"polite\" class=\"forminator-response-message forminator-error\" aria-hidden=\"true\"><\/div><div class=\"forminator-row\"><div id=\"section-1\" class=\"forminator-field-section forminator-col forminator-col-12 \"><div class=\"forminator-field\"><h2 class=\"forminator-title\">SECTION 21 \u2013 PATIENT INTAKE FORM<\/h2><h3 class=\"forminator-subtitle\">Section 21\u2019s: Before any medicine can be sold in South Africa, it must be approved by the South African Health Products Regulatory Authority (SAHPRA), who certifies that the medicine is safe, of good quality and is effective. Unless the medicine has gone through these processes, it cannot be on the shelves for sale. In exceptional circumstances, SAHPRA may permit access to unregistered medicines. This exception is permitted by section 21 of the Medicines and Related Substances Act, 101 of 1965 through a process that is commonly referred to as \u201ca section 21 application\u201d.<\/h3><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"section-2\" class=\"forminator-field-section forminator-col forminator-col-12 \"><div class=\"forminator-field\"><h2 class=\"forminator-title\">Dispensing of Medicinal Cannabis:<\/h2><h3 class=\"forminator-subtitle\">Under the Medicines Act, medical practitioners can apply to SAHPRA for permission to access and prescribe unregistered medicines \u2013 including cannabis \u2013 for their patients in certain exceptional circumstances. The only means by which a patient will be able to obtain Medicinal Cannabis in South Africa is through a medical practitioner who holds the relevant license to prescribe it, which license is obtained from SAHPRA. A Pharmacist registered accordingly with the relevant Pharmacy Council are able to provide medicinal cannabis when provided with a legitimate prescription from a medical practitioner. Medicinal Cannabis products may thus be made available to specific patients under medical supervision and through legal channels as confirmed by SAHPRA in the guideline document in this regard.<\/h3><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"section-3\" class=\"forminator-field-section forminator-col forminator-col-12 \"><div class=\"forminator-field\"><h2 class=\"forminator-title\">1. Supporting Documents Required:<\/h2><h3 class=\"forminator-subtitle\">\u2022 Notification of Payment \u2022 Copy of ID<\/h3><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"section-4\" class=\"forminator-field-section forminator-col forminator-col-12 \"><div class=\"forminator-field\"><h2 class=\"forminator-title\">1. PARTICULARS OF PATIENT:<\/h2><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"name-1\" class=\"forminator-field-name forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-name-1_6ac40d0896709\" id=\"forminator-field-name-1_6ac40d0896709-label\" class=\"forminator-label\">Title:<\/label><input type=\"text\" name=\"name-1\" value=\"\" placeholder=\"E.g. Mr, Mrs, Dr, Prof\" id=\"forminator-field-name-1_6ac40d0896709\" class=\"forminator-input forminator-name--field\" aria-required=\"false\" autocomplete=\"name\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"name-2\" class=\"forminator-field-name forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-name-2_6ac40d0896709\" id=\"forminator-field-name-2_6ac40d0896709-label\" class=\"forminator-label\">Full Names:<\/label><input type=\"text\" name=\"name-2\" value=\"\" placeholder=\"E.g. John Doe\" id=\"forminator-field-name-2_6ac40d0896709\" class=\"forminator-input forminator-name--field\" aria-required=\"false\" autocomplete=\"name\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"name-3\" class=\"forminator-field-name forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-name-3_6ac40d0896709\" id=\"forminator-field-name-3_6ac40d0896709-label\" class=\"forminator-label\">Surname:<\/label><input type=\"text\" name=\"name-3\" value=\"\" placeholder=\"E.g. Smith\" id=\"forminator-field-name-3_6ac40d0896709\" class=\"forminator-input forminator-name--field\" aria-required=\"false\" autocomplete=\"name\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"phone-1\" class=\"forminator-field-phone forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-phone-1_6ac40d0896709\" id=\"forminator-field-phone-1_6ac40d0896709-label\" class=\"forminator-label\">SA ID Number: <span class=\"forminator-required\">*<\/span><\/label><input type=\"text\" name=\"phone-1\" value=\"\" placeholder=\"E.g. 0001003400002\" id=\"forminator-field-phone-1_6ac40d0896709\" class=\"forminator-input forminator-field--phone\" data-required=\"1\" aria-required=\"true\" autocomplete=\"off\" maxlength=\"13\" data-validation=\"character_limit\" \/><span id=\"forminator-field-phone-1_6ac40d0896709-description\" class=\"forminator-description\" id=\"forminator-field-phone-1_6ac40d0896709-description\"><span data-limit=\"13\" data-type=\"\">0 \/ 13<\/span><\/span><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"name-4\" class=\"forminator-field-name forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-name-4_6ac40d0896709\" id=\"forminator-field-name-4_6ac40d0896709-label\" class=\"forminator-label\">Occupation:<\/label><input type=\"text\" name=\"name-4\" value=\"\" placeholder=\"E.g. Admin\" id=\"forminator-field-name-4_6ac40d0896709\" class=\"forminator-input forminator-name--field\" aria-required=\"false\" autocomplete=\"name\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"name-5\" class=\"forminator-field-name forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-name-5_6ac40d0896709\" id=\"forminator-field-name-5_6ac40d0896709-label\" class=\"forminator-label\">Age:<\/label><input type=\"text\" name=\"name-5\" value=\"\" placeholder=\"E.g. 21\" id=\"forminator-field-name-5_6ac40d0896709\" class=\"forminator-input forminator-name--field\" aria-required=\"false\" autocomplete=\"name\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"select-1\" class=\"forminator-field-select forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-form-2040__field--select-1_6ac40d0896709\" id=\"forminator-form-2040__field--select-1_6ac40d0896709-label\" class=\"forminator-label\">Gender:<\/label><select  id=\"forminator-form-2040__field--select-1_6ac40d0896709\" class=\"forminator-select--field forminator-select2 forminator-select2-multiple\" data-required=\"\" name=\"select-1\" data-default-value=\"one\" data-hidden-behavior=\"zero\" data-placeholder=\"Gender:\" data-search=\"false\" data-search-placeholder=\"Gender:\" data-checkbox=\"false\" data-allow-clear=\"false\" aria-labelledby=\"forminator-form-2040__field--select-1_6ac40d0896709-label\"><option value=\"\"  >Gender:<\/option><option value=\"one\" selected=\"selected\" data-calculation=\"0\">Male<\/option><option value=\"two\"  data-calculation=\"0\">Female<\/option><\/select><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"name-6\" class=\"forminator-field-name forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-name-6_6ac40d0896709\" id=\"forminator-field-name-6_6ac40d0896709-label\" class=\"forminator-label\">Weight (kg):<\/label><input type=\"text\" name=\"name-6\" value=\"\" placeholder=\"E.g. 60kg\" id=\"forminator-field-name-6_6ac40d0896709\" class=\"forminator-input forminator-name--field\" aria-required=\"false\" autocomplete=\"name\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"name-7\" class=\"forminator-field-name forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-name-7_6ac40d0896709\" id=\"forminator-field-name-7_6ac40d0896709-label\" class=\"forminator-label\">Height (cm):<\/label><input type=\"text\" name=\"name-7\" value=\"\" placeholder=\"E.g. 150cm\" id=\"forminator-field-name-7_6ac40d0896709\" class=\"forminator-input forminator-name--field\" aria-required=\"false\" autocomplete=\"name\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"address-1\" class=\"forminator-field-address forminator-col forminator-col-12 \"><div class=\"forminator-row\"><div id=\"address-1-street_address\" class=\"forminator-col\"><div class=\"forminator-field\"><label for=\"forminator-field-address-1-street_address_6ac40d0896709\" id=\"forminator-field-address-1-street_address_6ac40d0896709-label\" class=\"forminator-label\">Street Address<\/label><input type=\"text\" name=\"address-1-street_address\" placeholder=\"E.g. 42 Wallaby Way\" id=\"forminator-field-address-1-street_address_6ac40d0896709\" class=\"forminator-input\" data-required=\"\" aria-required=\"false\" autocomplete=\"address-line1\" value=\"\" \/><\/div><\/div><\/div><div class=\"forminator-row\" data-multiple=\"true\"><div id=\"address-1-city\" class=\"forminator-col forminator-col-6\"><div class=\"forminator-field\"><label for=\"forminator-field-address-1-city_6ac40d0896709\" id=\"forminator-field-address-1-city_6ac40d0896709-label\" class=\"forminator-label\">City<\/label><input type=\"text\" name=\"address-1-city\" placeholder=\"E.g. Durban North\" id=\"forminator-field-address-1-city_6ac40d0896709\" class=\"forminator-input\" data-required=\"\" aria-required=\"false\" autocomplete=\"address-level2\" value=\"\" \/><\/div><\/div><div id=\"address-1-state\" class=\"forminator-col forminator-col-6\"><div class=\"forminator-field\"><label for=\"forminator-field-address-1-state_6ac40d0896709\" id=\"forminator-field-address-1-state_6ac40d0896709-label\" class=\"forminator-label\">State\/Province<\/label><input type=\"text\" name=\"address-1-state\" placeholder=\"E.g. Western Cape\" id=\"forminator-field-address-1-state_6ac40d0896709\" class=\"forminator-input\" data-required=\"\" aria-required=\"false\" autocomplete=\"address-level1\" value=\"\" \/><\/div><\/div><\/div><div class=\"forminator-row\" data-multiple=\"true\"><div id=\"address-1-zip\" class=\"forminator-col forminator-col-6\"><div class=\"forminator-field\"><label for=\"forminator-field-address-1-zip_6ac40d0896709\" id=\"forminator-field-address-1-zip_6ac40d0896709-label\" class=\"forminator-label\">ZIP \/ Postal Code<\/label><input type=\"text\" name=\"address-1-zip\" placeholder=\"E.g. 0001\" id=\"forminator-field-address-1-zip_6ac40d0896709\" class=\"forminator-input\" autocomplete=\"postal-code\" value=\"\" \/><\/div><\/div><div id=\"address-1-country\" class=\"forminator-col forminator-col-6\"><div class=\"forminator-field\"><label for=\"forminator-field-2040__field--address-1-country_6ac40d0896709\" id=\"forminator-field-2040__field--address-1-country_6ac40d0896709-label\" class=\"forminator-label\">Country<\/label><select name=\"address-1-country\" id=\"forminator-field-2040__field--address-1-country_6ac40d0896709\" class=\"forminator-select2\" data-search=\"true\" data-placeholder=\"Select country\" autocomplete=\"country-name country\" data-default-value=\"\"><option value=\"\" data-country-code=\"\" selected=\"selected\"><\/option><option value=\"Afghanistan\" data-country-code=\"AF\" >Afghanistan<\/option><option value=\"Albania\" data-country-code=\"AL\" >Albania<\/option><option value=\"Algeria\" data-country-code=\"DZ\" >Algeria<\/option><option value=\"American Samoa\" data-country-code=\"AS\" >American Samoa<\/option><option value=\"Andorra\" data-country-code=\"AD\" >Andorra<\/option><option value=\"Angola\" data-country-code=\"AO\" >Angola<\/option><option value=\"Anguilla\" data-country-code=\"AI\" >Anguilla<\/option><option value=\"Antarctica\" data-country-code=\"AQ\" >Antarctica<\/option><option value=\"Antigua and Barbuda\" data-country-code=\"AG\" >Antigua and Barbuda<\/option><option value=\"Argentina\" data-country-code=\"AR\" >Argentina<\/option><option value=\"Armenia\" data-country-code=\"AM\" >Armenia<\/option><option value=\"Aruba\" data-country-code=\"AW\" >Aruba<\/option><option value=\"Australia\" data-country-code=\"AU\" >Australia<\/option><option value=\"Austria\" data-country-code=\"AT\" >Austria<\/option><option value=\"Azerbaijan\" data-country-code=\"AZ\" >Azerbaijan<\/option><option value=\"Bahamas\" data-country-code=\"BS\" >Bahamas<\/option><option value=\"Bahrain\" data-country-code=\"BH\" >Bahrain<\/option><option value=\"Bangladesh\" data-country-code=\"BD\" >Bangladesh<\/option><option value=\"Barbados\" data-country-code=\"BB\" >Barbados<\/option><option value=\"Belarus\" data-country-code=\"BY\" >Belarus<\/option><option value=\"Belgium\" data-country-code=\"BE\" >Belgium<\/option><option value=\"Belize\" data-country-code=\"BZ\" >Belize<\/option><option value=\"Benin\" data-country-code=\"BJ\" >Benin<\/option><option value=\"Bermuda\" data-country-code=\"BM\" >Bermuda<\/option><option value=\"Bhutan\" data-country-code=\"BT\" >Bhutan<\/option><option value=\"Bolivia\" data-country-code=\"BO\" >Bolivia<\/option><option value=\"Bosnia and Herzegovina\" data-country-code=\"BA\" >Bosnia and Herzegovina<\/option><option value=\"Botswana\" data-country-code=\"BW\" >Botswana<\/option><option value=\"Bouvet Island\" data-country-code=\"BV\" >Bouvet Island<\/option><option value=\"Brazil\" data-country-code=\"BR\" >Brazil<\/option><option value=\"British Indian Ocean Territory\" data-country-code=\"IO\" >British Indian Ocean Territory<\/option><option value=\"Brunei\" data-country-code=\"BN\" >Brunei<\/option><option value=\"Bulgaria\" data-country-code=\"BG\" >Bulgaria<\/option><option value=\"Burkina Faso\" data-country-code=\"BF\" >Burkina Faso<\/option><option value=\"Burundi\" data-country-code=\"BI\" >Burundi<\/option><option value=\"Cabo Verde\" data-country-code=\"CV\" >Cabo Verde<\/option><option value=\"Cambodia\" data-country-code=\"KH\" >Cambodia<\/option><option value=\"Cameroon\" data-country-code=\"CM\" >Cameroon<\/option><option value=\"Canada\" data-country-code=\"CA\" >Canada<\/option><option value=\"Cayman Islands\" data-country-code=\"KY\" >Cayman Islands<\/option><option value=\"Central African Republic\" data-country-code=\"CF\" >Central African Republic<\/option><option value=\"Chad\" data-country-code=\"TD\" >Chad<\/option><option value=\"Chile\" data-country-code=\"CL\" >Chile<\/option><option value=\"China, People's Republic of\" data-country-code=\"CN\" >China, People's Republic of<\/option><option value=\"Christmas Island\" data-country-code=\"CX\" >Christmas Island<\/option><option value=\"Cocos Islands\" data-country-code=\"CC\" >Cocos Islands<\/option><option value=\"Colombia\" data-country-code=\"CO\" >Colombia<\/option><option value=\"Comoros\" data-country-code=\"KM\" >Comoros<\/option><option value=\"Congo, Democratic Republic of the\" data-country-code=\"CD\" >Congo, Democratic Republic of the<\/option><option value=\"Congo, Republic of the\" data-country-code=\"CG\" >Congo, Republic of the<\/option><option value=\"Cook Islands\" data-country-code=\"CK\" >Cook Islands<\/option><option value=\"Costa Rica\" data-country-code=\"CR\" >Costa Rica<\/option><option value=\"Croatia\" data-country-code=\"HR\" >Croatia<\/option><option value=\"Cuba\" data-country-code=\"CU\" >Cuba<\/option><option value=\"Cura\u00e7ao\" data-country-code=\"CW\" >Cura\u00e7ao<\/option><option value=\"Cyprus\" data-country-code=\"CY\" >Cyprus<\/option><option value=\"Czech Republic\" data-country-code=\"CZ\" >Czech Republic<\/option><option value=\"C\u00f4te d'Ivoire\" data-country-code=\"CI\" >C\u00f4te d'Ivoire<\/option><option value=\"Denmark\" data-country-code=\"DK\" >Denmark<\/option><option value=\"Djibouti\" data-country-code=\"DJ\" >Djibouti<\/option><option value=\"Dominica\" data-country-code=\"DM\" >Dominica<\/option><option value=\"Dominican Republic\" data-country-code=\"DO\" >Dominican Republic<\/option><option value=\"East Timor\" data-country-code=\"TL\" >East Timor<\/option><option value=\"Ecuador\" data-country-code=\"EC\" >Ecuador<\/option><option value=\"Egypt\" data-country-code=\"EG\" >Egypt<\/option><option value=\"El Salvador\" data-country-code=\"SV\" >El Salvador<\/option><option value=\"Equatorial Guinea\" data-country-code=\"GQ\" >Equatorial Guinea<\/option><option value=\"Eritrea\" data-country-code=\"ER\" >Eritrea<\/option><option value=\"Estonia\" data-country-code=\"EE\" >Estonia<\/option><option value=\"Ethiopia\" data-country-code=\"ET\" >Ethiopia<\/option><option value=\"Falkland Islands\" data-country-code=\"FK\" >Falkland Islands<\/option><option value=\"Faroe Islands\" data-country-code=\"FO\" >Faroe Islands<\/option><option value=\"Fiji\" data-country-code=\"FJ\" >Fiji<\/option><option value=\"Finland\" data-country-code=\"FI\" >Finland<\/option><option value=\"France\" data-country-code=\"FR\" >France<\/option><option value=\"France, Metropolitan\" data-country-code=\"FX\" >France, Metropolitan<\/option><option value=\"French Guiana\" data-country-code=\"GF\" >French Guiana<\/option><option value=\"French Polynesia\" data-country-code=\"PF\" >French Polynesia<\/option><option value=\"French South Territories\" data-country-code=\"TF\" >French South Territories<\/option><option value=\"Gabon\" data-country-code=\"GA\" >Gabon<\/option><option value=\"Gambia\" data-country-code=\"GM\" >Gambia<\/option><option value=\"Georgia\" data-country-code=\"GE\" >Georgia<\/option><option value=\"Germany\" data-country-code=\"DE\" >Germany<\/option><option value=\"Ghana\" data-country-code=\"GH\" >Ghana<\/option><option value=\"Gibraltar\" data-country-code=\"GI\" >Gibraltar<\/option><option value=\"Greece\" data-country-code=\"GR\" >Greece<\/option><option value=\"Greenland\" data-country-code=\"GL\" >Greenland<\/option><option value=\"Grenada\" data-country-code=\"GD\" >Grenada<\/option><option value=\"Guadeloupe\" data-country-code=\"GP\" >Guadeloupe<\/option><option value=\"Guam\" data-country-code=\"GU\" >Guam<\/option><option value=\"Guatemala\" data-country-code=\"GT\" >Guatemala<\/option><option value=\"Guernsey\" data-country-code=\"GG\" >Guernsey<\/option><option value=\"Guinea\" data-country-code=\"GN\" >Guinea<\/option><option value=\"Guinea-Bissau\" data-country-code=\"GW\" >Guinea-Bissau<\/option><option value=\"Guyana\" data-country-code=\"GY\" >Guyana<\/option><option value=\"Haiti\" data-country-code=\"HT\" >Haiti<\/option><option value=\"Heard Island And Mcdonald Island\" data-country-code=\"HM\" >Heard Island And Mcdonald Island<\/option><option value=\"Honduras\" data-country-code=\"HN\" >Honduras<\/option><option value=\"Hong Kong\" data-country-code=\"HK\" >Hong Kong<\/option><option value=\"Hungary\" data-country-code=\"HU\" >Hungary<\/option><option value=\"Iceland\" data-country-code=\"IS\" >Iceland<\/option><option value=\"India\" data-country-code=\"IN\" >India<\/option><option value=\"Indonesia\" data-country-code=\"ID\" >Indonesia<\/option><option value=\"Iran\" data-country-code=\"IR\" >Iran<\/option><option value=\"Iraq\" data-country-code=\"IQ\" >Iraq<\/option><option value=\"Ireland\" data-country-code=\"IE\" >Ireland<\/option><option value=\"Israel\" data-country-code=\"IL\" >Israel<\/option><option value=\"Italy\" data-country-code=\"IT\" >Italy<\/option><option value=\"Jamaica\" data-country-code=\"JM\" >Jamaica<\/option><option value=\"Japan\" data-country-code=\"JP\" >Japan<\/option><option value=\"Jersey\" data-country-code=\"JE\" >Jersey<\/option><option value=\"Johnston Island\" data-country-code=\"JT\" >Johnston Island<\/option><option value=\"Jordan\" data-country-code=\"JO\" >Jordan<\/option><option value=\"Kazakhstan\" data-country-code=\"KZ\" >Kazakhstan<\/option><option value=\"Kenya\" data-country-code=\"KE\" >Kenya<\/option><option value=\"Kiribati\" data-country-code=\"KI\" >Kiribati<\/option><option value=\"Korea, Democratic People's Republic of\" data-country-code=\"KP\" >Korea, Democratic People's Republic of<\/option><option value=\"Korea, Republic of\" data-country-code=\"KR\" >Korea, Republic of<\/option><option value=\"Kosovo\" data-country-code=\"XK\" >Kosovo<\/option><option value=\"Kuwait\" data-country-code=\"KW\" >Kuwait<\/option><option value=\"Kyrgyzstan\" data-country-code=\"KG\" >Kyrgyzstan<\/option><option value=\"Lao People's Democratic Republic\" data-country-code=\"LA\" >Lao People's Democratic Republic<\/option><option value=\"Latvia\" data-country-code=\"LV\" >Latvia<\/option><option value=\"Lebanon\" data-country-code=\"LB\" >Lebanon<\/option><option value=\"Lesotho\" data-country-code=\"LS\" >Lesotho<\/option><option value=\"Liberia\" data-country-code=\"LR\" >Liberia<\/option><option value=\"Libya\" data-country-code=\"LY\" >Libya<\/option><option value=\"Liechtenstein\" data-country-code=\"LI\" >Liechtenstein<\/option><option value=\"Lithuania\" data-country-code=\"LT\" >Lithuania<\/option><option value=\"Luxembourg\" data-country-code=\"LU\" >Luxembourg<\/option><option value=\"Macau\" data-country-code=\"MO\" >Macau<\/option><option value=\"Madagascar\" data-country-code=\"MG\" >Madagascar<\/option><option value=\"Malawi\" data-country-code=\"MW\" >Malawi<\/option><option value=\"Malaysia\" data-country-code=\"MY\" >Malaysia<\/option><option value=\"Maldives\" data-country-code=\"MV\" >Maldives<\/option><option value=\"Mali\" data-country-code=\"ML\" >Mali<\/option><option value=\"Malta\" data-country-code=\"MT\" >Malta<\/option><option value=\"Marshall Islands\" data-country-code=\"MH\" >Marshall Islands<\/option><option value=\"Martinique\" data-country-code=\"MQ\" >Martinique<\/option><option value=\"Mauritania\" data-country-code=\"MR\" >Mauritania<\/option><option value=\"Mauritius\" data-country-code=\"MU\" >Mauritius<\/option><option value=\"Mayotte\" data-country-code=\"YT\" >Mayotte<\/option><option value=\"Mexico\" data-country-code=\"MX\" >Mexico<\/option><option value=\"Micronesia\" data-country-code=\"FM\" >Micronesia<\/option><option value=\"Moldova\" data-country-code=\"MD\" >Moldova<\/option><option value=\"Monaco\" data-country-code=\"MC\" >Monaco<\/option><option value=\"Mongolia\" data-country-code=\"MN\" >Mongolia<\/option><option value=\"Montenegro\" data-country-code=\"ME\" >Montenegro<\/option><option value=\"Montserrat\" data-country-code=\"MS\" >Montserrat<\/option><option value=\"Morocco\" data-country-code=\"MA\" >Morocco<\/option><option value=\"Mozambique\" data-country-code=\"MZ\" >Mozambique<\/option><option value=\"Myanmar\" data-country-code=\"MM\" >Myanmar<\/option><option value=\"Namibia\" data-country-code=\"NA\" >Namibia<\/option><option value=\"Nauru\" data-country-code=\"NR\" >Nauru<\/option><option value=\"Nepal\" data-country-code=\"NP\" >Nepal<\/option><option value=\"Netherlands\" data-country-code=\"NL\" >Netherlands<\/option><option value=\"Netherlands Antilles\" data-country-code=\"AN\" >Netherlands Antilles<\/option><option value=\"New Caledonia\" data-country-code=\"NC\" >New Caledonia<\/option><option value=\"New Zealand\" data-country-code=\"NZ\" >New Zealand<\/option><option value=\"Nicaragua\" data-country-code=\"NI\" >Nicaragua<\/option><option value=\"Niger\" data-country-code=\"NE\" >Niger<\/option><option value=\"Nigeria\" data-country-code=\"NG\" >Nigeria<\/option><option value=\"Niue\" data-country-code=\"NU\" >Niue<\/option><option value=\"Norfolk Island\" data-country-code=\"NF\" >Norfolk Island<\/option><option value=\"North Macedonia\" data-country-code=\"MK\" >North Macedonia<\/option><option value=\"Northern Mariana Islands\" data-country-code=\"MP\" >Northern Mariana Islands<\/option><option value=\"Norway\" data-country-code=\"NO\" >Norway<\/option><option value=\"Oman\" data-country-code=\"OM\" >Oman<\/option><option value=\"Pakistan\" data-country-code=\"PK\" >Pakistan<\/option><option value=\"Palau\" data-country-code=\"PW\" >Palau<\/option><option value=\"Palestine, State of\" data-country-code=\"PS\" >Palestine, State of<\/option><option value=\"Panama\" data-country-code=\"PA\" >Panama<\/option><option value=\"Papua New Guinea\" data-country-code=\"PG\" >Papua New Guinea<\/option><option value=\"Paraguay\" data-country-code=\"PY\" >Paraguay<\/option><option value=\"Peru\" data-country-code=\"PE\" >Peru<\/option><option value=\"Philippines\" data-country-code=\"PH\" >Philippines<\/option><option value=\"Pitcairn Islands\" data-country-code=\"PN\" >Pitcairn Islands<\/option><option value=\"Poland\" data-country-code=\"PL\" >Poland<\/option><option value=\"Portugal\" data-country-code=\"PT\" >Portugal<\/option><option value=\"Puerto Rico\" data-country-code=\"PR\" >Puerto Rico<\/option><option value=\"Qatar\" data-country-code=\"QA\" >Qatar<\/option><option value=\"Reunion Island\" data-country-code=\"RE\" >Reunion Island<\/option><option value=\"Romania\" data-country-code=\"RO\" >Romania<\/option><option value=\"Russia\" data-country-code=\"RU\" >Russia<\/option><option value=\"Rwanda\" data-country-code=\"RW\" >Rwanda<\/option><option value=\"Saint Helena\" data-country-code=\"SH\" >Saint Helena<\/option><option value=\"Saint Kitts and Nevis\" data-country-code=\"KN\" >Saint Kitts and Nevis<\/option><option value=\"Saint Lucia\" data-country-code=\"LC\" >Saint Lucia<\/option><option value=\"Saint Pierre & Miquelon\" data-country-code=\"PM\" >Saint Pierre & Miquelon<\/option><option value=\"Saint Vincent and the Grenadines\" data-country-code=\"VC\" >Saint Vincent and the Grenadines<\/option><option value=\"Samoa\" data-country-code=\"WS\" >Samoa<\/option><option value=\"San Marino\" data-country-code=\"SM\" >San Marino<\/option><option value=\"Sao Tome and Principe\" data-country-code=\"ST\" >Sao Tome and Principe<\/option><option value=\"Saudi Arabia\" data-country-code=\"SA\" >Saudi Arabia<\/option><option value=\"Senegal\" data-country-code=\"SN\" >Senegal<\/option><option value=\"Serbia\" data-country-code=\"RS\" >Serbia<\/option><option value=\"Seychelles\" data-country-code=\"SC\" >Seychelles<\/option><option value=\"Sierra Leone\" data-country-code=\"SL\" >Sierra Leone<\/option><option value=\"Singapore\" data-country-code=\"SG\" >Singapore<\/option><option value=\"Sint Maarten\" data-country-code=\"MF\" >Sint Maarten<\/option><option value=\"Slovakia\" data-country-code=\"SK\" >Slovakia<\/option><option value=\"Slovenia\" data-country-code=\"SI\" >Slovenia<\/option><option value=\"Solomon Islands\" data-country-code=\"SB\" >Solomon Islands<\/option><option value=\"Somalia\" data-country-code=\"SO\" >Somalia<\/option><option value=\"South Africa\" data-country-code=\"ZA\" >South Africa<\/option><option value=\"South Georgia and South Sandwich\" data-country-code=\"GS\" >South Georgia and South Sandwich<\/option><option value=\"Spain\" data-country-code=\"ES\" >Spain<\/option><option value=\"Sri Lanka\" data-country-code=\"LK\" >Sri Lanka<\/option><option value=\"Stateless Persons\" data-country-code=\"XX\" >Stateless Persons<\/option><option value=\"Sudan\" data-country-code=\"SD\" >Sudan<\/option><option value=\"Sudan, South\" data-country-code=\"SS\" >Sudan, South<\/option><option value=\"Suriname\" data-country-code=\"SR\" >Suriname<\/option><option value=\"Svalbard and Jan Mayen\" data-country-code=\"SJ\" >Svalbard and Jan Mayen<\/option><option value=\"Swaziland\" data-country-code=\"SZ\" >Swaziland<\/option><option value=\"Sweden\" data-country-code=\"SE\" >Sweden<\/option><option value=\"Switzerland\" data-country-code=\"CH\" >Switzerland<\/option><option value=\"Syria\" data-country-code=\"SY\" >Syria<\/option><option value=\"Taiwan, Republic of China\" data-country-code=\"TW\" >Taiwan, Republic of China<\/option><option value=\"Tajikistan\" data-country-code=\"TJ\" >Tajikistan<\/option><option value=\"Tanzania\" data-country-code=\"TZ\" >Tanzania<\/option><option value=\"Thailand\" data-country-code=\"TH\" >Thailand<\/option><option value=\"Togo\" data-country-code=\"TG\" >Togo<\/option><option value=\"Tokelau\" data-country-code=\"TK\" >Tokelau<\/option><option value=\"Tonga\" data-country-code=\"TO\" >Tonga<\/option><option value=\"Trinidad and Tobago\" data-country-code=\"TT\" >Trinidad and Tobago<\/option><option value=\"Tunisia\" data-country-code=\"TN\" >Tunisia<\/option><option value=\"Turkey\" data-country-code=\"TR\" >Turkey<\/option><option value=\"Turkmenistan\" data-country-code=\"TM\" >Turkmenistan<\/option><option value=\"Turks And Caicos Islands\" data-country-code=\"TC\" >Turks And Caicos Islands<\/option><option value=\"Tuvalu\" data-country-code=\"TV\" >Tuvalu<\/option><option value=\"US Minor Outlying Islands\" data-country-code=\"UM\" >US Minor Outlying Islands<\/option><option value=\"Uganda\" data-country-code=\"UG\" >Uganda<\/option><option value=\"Ukraine\" data-country-code=\"UA\" >Ukraine<\/option><option value=\"United Arab Emirates\" data-country-code=\"AE\" >United Arab Emirates<\/option><option value=\"United Kingdom\" data-country-code=\"GB\" >United Kingdom<\/option><option value=\"United States of America (USA)\" data-country-code=\"US\" >United States of America (USA)<\/option><option value=\"Uruguay\" data-country-code=\"UY\" >Uruguay<\/option><option value=\"Uzbekistan\" data-country-code=\"UZ\" >Uzbekistan<\/option><option value=\"Vanuatu\" data-country-code=\"VU\" >Vanuatu<\/option><option value=\"Vatican City\" data-country-code=\"VA\" >Vatican City<\/option><option value=\"Venezuela\" data-country-code=\"VE\" >Venezuela<\/option><option value=\"Vietnam\" data-country-code=\"VN\" >Vietnam<\/option><option value=\"Virgin Islands, British\" data-country-code=\"VG\" >Virgin Islands, British<\/option><option value=\"Virgin Islands, U.S.\" data-country-code=\"VI\" >Virgin Islands, U.S.<\/option><option value=\"Wallis And Futuna Islands\" data-country-code=\"WF\" >Wallis And Futuna Islands<\/option><option value=\"Western Sahara\" data-country-code=\"EH\" >Western Sahara<\/option><option value=\"Yemen\" data-country-code=\"YE\" >Yemen<\/option><option value=\"Zambia\" data-country-code=\"ZM\" >Zambia<\/option><option value=\"Zimbabwe\" data-country-code=\"ZW\" >Zimbabwe<\/option><\/select><\/div><\/div><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"phone-2\" class=\"forminator-field-phone forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-phone-2_6ac40d0896709\" id=\"forminator-field-phone-2_6ac40d0896709-label\" class=\"forminator-label\">Phone<\/label><input type=\"text\" name=\"phone-2\" value=\"\" placeholder=\"E.g. +27 81 000 0001\" id=\"forminator-field-phone-2_6ac40d0896709\" class=\"forminator-input forminator-field--phone\" data-required=\"\" aria-required=\"false\" autocomplete=\"off\" data-national_mode=\"disabled\" data-country=\"za\" data-validation=\"international\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"email-1\" class=\"forminator-field-email forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-email-1_6ac40d0896709\" id=\"forminator-field-email-1_6ac40d0896709-label\" class=\"forminator-label\">Email Address<\/label><input type=\"email\" name=\"email-1\" value=\"\" placeholder=\"E.g. john@doe.com\" id=\"forminator-field-email-1_6ac40d0896709\" class=\"forminator-input forminator-email--field\" data-required=\"\" aria-required=\"false\" autocomplete=\"email\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"textarea-1\" class=\"forminator-field-textarea forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-textarea-1_6ac40d0896709\" id=\"forminator-field-textarea-1_6ac40d0896709-label\" class=\"forminator-label\">Diagnosis \u2013 Full description including severity, staging and prognosis where applicable:<\/label><textarea name=\"textarea-1\" placeholder=\"Example: Chronic Pain, Anxiety, Fibromyalgia etc.\n\u2013 Please give a full description.\" id=\"forminator-field-textarea-1_6ac40d0896709\" class=\"forminator-textarea\" rows=\"6\" style=\"min-height:140px;\" ><\/textarea><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"textarea-2\" class=\"forminator-field-textarea forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-textarea-2_6ac40d0896709\" id=\"forminator-field-textarea-2_6ac40d0896709-label\" class=\"forminator-label\">Details of current treatment regimen for the above diagnosis. Include medical, surgical and other treatment:<\/label><textarea name=\"textarea-2\" placeholder=\"Example: Aspirin, Ibuprofen, Naproxen, Serotonin\nand Norepinephrine.\" id=\"forminator-field-textarea-2_6ac40d0896709\" class=\"forminator-textarea\" rows=\"6\" style=\"min-height:140px;\" ><\/textarea><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"textarea-3\" class=\"forminator-field-textarea forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-textarea-3_6ac40d0896709\" id=\"forminator-field-textarea-3_6ac40d0896709-label\" class=\"forminator-label\">Do you suffer from any other conditions not yet mentioned? If yes, please specify as well as current treatment.<\/label><textarea name=\"textarea-3\" placeholder=\"Example: High Blood Pressure, Cholesterol,\nDiabetes etc.\" id=\"forminator-field-textarea-3_6ac40d0896709\" class=\"forminator-textarea\" rows=\"6\" style=\"min-height:140px;\" ><\/textarea><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"checkbox-1\" class=\"forminator-field-checkbox forminator-col forminator-col-12 \"><div role=\"group\" class=\"forminator-field\" aria-labelledby=\"forminator-checkbox-group-forminator-field-checkbox-1-6ac40d0896709-label\"><span id=\"forminator-checkbox-group-forminator-field-checkbox-1-6ac40d0896709-label\" class=\"forminator-label\">Do you smoke Cannabis?<\/span><label id=\"forminator-field-checkbox-1-1-6ac40d0896709-label\" for=\"forminator-field-checkbox-1-1-6ac40d0896709\" class=\"forminator-checkbox\" title=\"Yes\"><input type=\"checkbox\" name=\"checkbox-1[]\" value=\"one\" id=\"forminator-field-checkbox-1-1-6ac40d0896709\" aria-labelledby=\"forminator-field-checkbox-1-1-6ac40d0896709-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Yes<\/span><\/label><label id=\"forminator-field-checkbox-1-2-6ac40d0896709-label\" for=\"forminator-field-checkbox-1-2-6ac40d0896709\" class=\"forminator-checkbox\" title=\"No\"><input type=\"checkbox\" name=\"checkbox-1[]\" value=\"two\" id=\"forminator-field-checkbox-1-2-6ac40d0896709\" aria-labelledby=\"forminator-field-checkbox-1-2-6ac40d0896709-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">No<\/span><\/label><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"textarea-4\" class=\"forminator-field-textarea forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-textarea-4_6ac40d0896709\" id=\"forminator-field-textarea-4_6ac40d0896709-label\" class=\"forminator-label\">Do you use Cannabis in any other form?<\/label><textarea name=\"textarea-4\" placeholder=\"Specify:\" id=\"forminator-field-textarea-4_6ac40d0896709\" class=\"forminator-textarea\" rows=\"6\" style=\"min-height:140px;\" ><\/textarea><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"section-5\" class=\"forminator-field-section forminator-col forminator-col-12 \"><div class=\"forminator-field\"><h2 class=\"forminator-title\">2. PICK-UP POINT REQUEST:<\/h2><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"consent-1\" class=\"forminator-field-consent forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-consent-1_6ac40d0896709\" id=\"forminator-field-consent-1_6ac40d0896709-label\" class=\"forminator-label\">Consent <span class=\"forminator-required\">*<\/span><\/label><div class=\"forminator-checkbox__wrapper\"><label id=\"forminator-field-consent-1_6ac40d0896709__label\" class=\"forminator-checkbox forminator-consent\" aria-labelledby=\"forminator-field-consent-1_6ac40d0896709-label\"><input type=\"checkbox\" name=\"consent-1\" id=\"forminator-field-consent-1_6ac40d0896709\" value=\"checked\" aria-labelledby=\"forminator-field-consent-1_6ac40d0896709-label\" aria-describedby=\"forminator-field-consent-1_6ac40d0896709__description\" data-required=\"true\" aria-required=\"true\" \/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><\/label><div id=\"forminator-field-consent-1_6ac40d0896709__description\" class=\"forminator-checkbox__label forminator-consent__label\"><p>Herewith I, would like to request that my medicine be sent to the following pick-up point:<\/p><\/div><\/div><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"textarea-5\" class=\"forminator-field-textarea forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-textarea-5_6ac40d0896709\" id=\"forminator-field-textarea-5_6ac40d0896709-label\" class=\"forminator-label\">Store Name:<\/label><textarea name=\"textarea-5\" placeholder=\"E.g. ROOFTOP420 FLORIDA\" id=\"forminator-field-textarea-5_6ac40d0896709\" class=\"forminator-textarea\" rows=\"6\" style=\"min-height:140px;\" ><\/textarea><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"textarea-6\" class=\"forminator-field-textarea forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-textarea-6_6ac40d0896709\" id=\"forminator-field-textarea-6_6ac40d0896709-label\" class=\"forminator-label\">Store Address:<\/label><textarea name=\"textarea-6\" placeholder=\"E.g. Florida Fields, 297 Florida Rd, Morningside, Durban, 4410\" id=\"forminator-field-textarea-6_6ac40d0896709\" class=\"forminator-textarea\" rows=\"6\" style=\"min-height:140px;\" ><\/textarea><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"textarea-7\" class=\"forminator-field-textarea forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-textarea-7_6ac40d0896709\" id=\"forminator-field-textarea-7_6ac40d0896709-label\" class=\"forminator-label\">Full Name of Patient:<\/label><textarea name=\"textarea-7\" placeholder=\"E.g. John Smith\" id=\"forminator-field-textarea-7_6ac40d0896709\" class=\"forminator-textarea\" rows=\"6\" style=\"min-height:140px;\" ><\/textarea><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"signature-2\" class=\"forminator-field-signature forminator-col forminator-col-12 \"><div class=\"forminator-field forminator-field-signature\"><label for=\"forminator-field-ctlSignature6ac40d089886c\" id=\"forminator-field-ctlSignature6ac40d089886c-label\" class=\"forminator-label\">Signature <span class=\"forminator-required\">*<\/span><\/label><div class=\"forminator-signature\" data-elementheight=\"180\"><span id=\"ctlSignature6ac40d089886c_placeholder\" class=\"forminator-signature--placeholder\" aria-hidden=\"true\">Start signing your signature here<\/span><div id=\"ctlSignature6ac40d089886c_Container\" class=\"forminator-signature--container\"><canvas id=\"ctlSignature6ac40d089886c\" class=\"forminator-signature-canvas\" height=\"180\" tabindex=\"-1\"><p>Your browser does not support e-Signature field.<\/p><\/canvas><\/div><\/div><input type=\"hidden\" name=\"field-signature-2\" value=\"6ac40d089886c\" class=\"signature-prefix\"><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"date-1\" class=\"forminator-field-date forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-date-1-picker_6ac40d0896709\" id=\"forminator-field-date-1-picker_6ac40d0896709-label\" class=\"forminator-label\">Date<\/label><div class=\"forminator-input-with-icon\"><span class=\"forminator-icon-calendar\" aria-hidden=\"true\"><\/span><input autocomplete=\"off\" type=\"text\" size=\"1\" name=\"date-1\" value=\"\" placeholder=\"Choose Date\" id=\"forminator-field-date-1-picker_6ac40d0896709\" class=\"forminator-input forminator-datepicker\" data-required=\"\" data-format=\"mm\/dd\/yy\" data-restrict-type=\"\" data-restrict=\"\" data-start-year=\"1926\" data-end-year=\"2126\" data-past-dates=\"enable\" data-start-of-week=\"1\" data-start-date=\"\" data-end-date=\"\" data-start-field=\"\" data-end-field=\"\" data-start-offset=\"\" data-end-offset=\"\" data-disable-date=\"\" data-disable-range=\"\" \/><\/div><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"section-6\" class=\"forminator-field-section forminator-col forminator-col-12 \"><div class=\"forminator-field\"><h2 class=\"forminator-title\">3. TERMS AND CONDITIONS:<\/h2><h3 class=\"forminator-subtitle\">1. There will be no refund of application fees for any reason after there has been any work done on the application. As long as the application has been sent to the relevant department, work is considered to have been done and the application fee will neither be refundable nor transferable. 2. The South African Health Products Regulatory Authority is responsible for the authorization of Section 21 Applications in terms of Section 21 of Act 101 of 1965. Should an application be unsuccessful and or be withdrawn by the Authority neither The Health Centre Pharmacy (Pty) Ltd, CBD Full Spectrum Manufacturers International (Pty) Ltd and or its approved Pick-Up points can be held liable. 3. The Health Centre Pharmacy (Pty) Ltd, CBD Full Spectrum Manufacturers International (Pty) Ltd and or its approved Pick-Up Points will not take any responsibility or provide any assistance should an event arise where the product has not been received from one of our approved Pick-Up Points, the product is not in the correct packaging as dispensed directly from The Health Centre Pharmacy (Pty) Ltd, where an individual has more than the allowed quantity as per the individual\u2019s prescription, or where the law was broken (for example, using the product while driving or in a public space where it is not permitted).<\/h3><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"textarea-8\" class=\"forminator-field-textarea forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-textarea-8_6ac40d0896709\" id=\"forminator-field-textarea-8_6ac40d0896709-label\" class=\"forminator-label\">Full Name of Patient:<\/label><textarea name=\"textarea-8\" placeholder=\"E.g. John Smith\" id=\"forminator-field-textarea-8_6ac40d0896709\" class=\"forminator-textarea\" rows=\"6\" style=\"min-height:140px;\" ><\/textarea><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"signature-1\" class=\"forminator-field-signature forminator-col forminator-col-12 \"><div class=\"forminator-field forminator-field-signature\"><label for=\"forminator-field-ctlSignature6ac40d08988fd\" id=\"forminator-field-ctlSignature6ac40d08988fd-label\" class=\"forminator-label\">Signature <span class=\"forminator-required\">*<\/span><\/label><div class=\"forminator-signature\" data-elementheight=\"180\"><span id=\"ctlSignature6ac40d08988fd_placeholder\" class=\"forminator-signature--placeholder\" aria-hidden=\"true\">Start signing your signature here<\/span><div id=\"ctlSignature6ac40d08988fd_Container\" class=\"forminator-signature--container\"><canvas id=\"ctlSignature6ac40d08988fd\" class=\"forminator-signature-canvas\" height=\"180\" tabindex=\"-1\"><p>Your browser does not support e-Signature field.<\/p><\/canvas><\/div><\/div><input type=\"hidden\" name=\"field-signature-1\" value=\"6ac40d08988fd\" class=\"signature-prefix\"><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"date-2\" class=\"forminator-field-date forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-date-2-picker_6ac40d0896709\" id=\"forminator-field-date-2-picker_6ac40d0896709-label\" class=\"forminator-label\">Date<\/label><div class=\"forminator-input-with-icon\"><span class=\"forminator-icon-calendar\" aria-hidden=\"true\"><\/span><input autocomplete=\"off\" type=\"text\" size=\"1\" name=\"date-2\" value=\"\" placeholder=\"Choose Date\" id=\"forminator-field-date-2-picker_6ac40d0896709\" class=\"forminator-input forminator-datepicker\" data-required=\"\" data-format=\"mm\/dd\/yy\" data-restrict-type=\"\" data-restrict=\"\" data-start-year=\"1926\" data-end-year=\"2126\" data-past-dates=\"enable\" data-start-of-week=\"1\" data-start-date=\"\" data-end-date=\"\" data-start-field=\"\" data-end-field=\"\" data-start-offset=\"\" data-end-offset=\"\" data-disable-date=\"\" data-disable-range=\"\" \/><\/div><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"consent-2\" class=\"forminator-field-consent forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-consent-2_6ac40d0896709\" id=\"forminator-field-consent-2_6ac40d0896709-label\" class=\"forminator-label\">4. INFORMED CONSENT FORM: <span class=\"forminator-required\">*<\/span><\/label><div class=\"forminator-checkbox__wrapper\"><label id=\"forminator-field-consent-2_6ac40d0896709__label\" class=\"forminator-checkbox forminator-consent\" aria-labelledby=\"forminator-field-consent-2_6ac40d0896709-label\"><input type=\"checkbox\" name=\"consent-2\" id=\"forminator-field-consent-2_6ac40d0896709\" value=\"checked\" aria-labelledby=\"forminator-field-consent-2_6ac40d0896709-label\" aria-describedby=\"forminator-field-consent-2_6ac40d0896709__description\" data-required=\"true\" aria-required=\"true\" \/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><\/label><div id=\"forminator-field-consent-2_6ac40d0896709__description\" class=\"forminator-checkbox__label forminator-consent__label\"><p>I, voluntarily agree to be treated with a medication namely 1% (one percent) or more Delta-9 Tetrahydrocannabinol which is not registered in South Africa.<\/p>\n<p>I confirm that I have been fully informed and my questions answered 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 South Africa and that:<br>- 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 SAHPRA.<br>- the medication will only be supplied to and used by and on me once specific approval has been obtained from SAHPRA.<br>- appropriate measures will be taken to prevent, monitor and manage the unwanted effects on me of the unregistered medication.<br>- use of the unregistered medication on and by me is for managing my disease and not for medical research.<br>- I will be free to stop using the medication at any time and that I will inform my (treating) doctor accordingly.<\/p><\/div><\/div><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"date-3\" class=\"forminator-field-date forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-date-3-picker_6ac40d0896709\" id=\"forminator-field-date-3-picker_6ac40d0896709-label\" class=\"forminator-label\">Date<\/label><div class=\"forminator-input-with-icon\"><span class=\"forminator-icon-calendar\" aria-hidden=\"true\"><\/span><input autocomplete=\"off\" type=\"text\" size=\"1\" name=\"date-3\" value=\"\" placeholder=\"Choose Date\" id=\"forminator-field-date-3-picker_6ac40d0896709\" class=\"forminator-input forminator-datepicker\" data-required=\"\" data-format=\"mm\/dd\/yy\" data-restrict-type=\"\" data-restrict=\"\" data-start-year=\"1926\" data-end-year=\"2126\" data-past-dates=\"enable\" data-start-of-week=\"1\" data-start-date=\"\" data-end-date=\"\" data-start-field=\"\" data-end-field=\"\" data-start-offset=\"\" data-end-offset=\"\" data-disable-date=\"\" data-disable-range=\"\" \/><\/div><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"textarea-9\" class=\"forminator-field-textarea forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-textarea-9_6ac40d0896709\" id=\"forminator-field-textarea-9_6ac40d0896709-label\" class=\"forminator-label\">Full Name of patient\/guardian:<\/label><textarea name=\"textarea-9\" placeholder=\"E.g. John Smith\" id=\"forminator-field-textarea-9_6ac40d0896709\" class=\"forminator-textarea\" rows=\"6\" style=\"min-height:140px;\" ><\/textarea><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"upload-1\" class=\"forminator-field-upload forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-upload-1_6ac40d0896709\" id=\"forminator-field-upload-1_6ac40d0896709-label\" class=\"forminator-label\">SA ID Upload file <span class=\"forminator-required\">*<\/span><\/label><div class=\"forminator-file-upload \" data-element=\"upload-1_6ac40d0896709\"><input type=\"file\" name=\"upload-1\" id=\"forminator-field-upload-1_6ac40d0896709\" class=\"forminator-input-file-required do-validate\" 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