Curabliss | Section 21 Medical Cannabis Application Form

CuraBliss - Hazelwood Clinical Patient On-boarding

Please ensure all information is accurate before submitting this form. This is a signed 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.

1/4Personal Details

Title

First Name

Last Name

Age

Height (in cm)

Weight (in kg's)

Occupation

Phone Number

Nationality

SA Citizen

Foreign National

ID Number

Upload ID/Passport

Upload or Take Photo of ID/Passport

2/4Residential Address

3/4Medical History

Ailments

4/4Declarations

Patient Consent I consent to be onboarded as a medical cannabis patient and understand my data may be used for research under SAHPRA oversight.

Declarations I confirm that I am over 18 I am not pregnant or breastfeeding I have not been diagnosed with Psychosis or Schizophrenia