Section 21 Application Form
Please ensure all information is accurate before submitting this form. This is a application form, and once submitted, it cannot be altered unless our team provides you with an opportunity to amend your submission during the review process. Double-check your details to avoid delays in your Section 21 license application.
Name
*
Mr.
Mrs.
Miss.
Title
First Name
Last Name
Age
*
Weight (kg)
*
Height (cm)
*
Occupation
*
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
Please enter a valid email address.
Address
*
Street Address
Street Address Line 2
City
Province
Postal / Zip Code
Upload ID/Passport
*
Browse Files
Drag and drop files here
Choose a file
If you are a non-South African citizen, you must upload a copy of your passport (both front and back). For South African citizens, upload your ID (both front and back). Accepted formats: PDF, JPG, JPEG, PNG.
Cancel
of
Related reason for the application to use unregistered medication.
*
Insomnia
Chronic Pain (pain is regarded as chronic when it lasts or recurs for more than 3 months).
Anxiety
Neuropathic Pain
Multiple Sclerosis
Endometriosis
Chemotherapy Induced Nausea and Vomiting
Arthritis
Epilepsy
Fibromyalgia
Back Pain and/or Neck Pain
Palliative Care
Other
Patient Consent
By submitting below, I acknowledge that this medication/device is for managing my condition, not for research. Any research using my data requires my specific approval and SAHPRA oversight, with results shared with SAHPRA. I can request a copy of this form, which will also be available to my healthcare professionals.
Eligibility Declaration.
*
I can confirm that i am over the age of 18
I have never been diagnosed with Schizophrenia or Psychosis
I confirm that I am not pregnant or breastfeeding
Submit
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