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			Booking Summary
			
				
					Condition
					—
				
				
					Doctor
					—
				
				
					Date & Time
					—
				
				
					Consultation fee
					R 450.00
				
				
					SAHPRA application fee
					R 400.00
				
				
					Total
					R 850.00
				
			
		

		
			
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		This doctor manages bookings directly. Use the contact details below to arrange your appointment.

		

		
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			Your booking has been confirmed! Please complete the medical intake form below before your appointment.
		

		
                

                        Personal Information
First Name(Required)
Last Name(Required)
Mobile Number(Required)
Email(Required)
                            
                        
Title(Required)
Gender(Required)
Confirm your ID or Passport(Required)
			
					
					ID
			
			
					
					Passport
			
ID Upload(Required)Max. file size: 64 MB.
 
Passport Upload(Required)Max. file size: 64 MB.
 
ID Number(Required)
Passport Number(Required)
Occupation(Required)
Height (CM)(Required)
Weight (KG)(Required)
Address
Residential Address(Required)    
                    
                         
                                        
                                        Street Address
                                    
                                        
                                        Address Line 2
                                    
                                    
                                    City
                                 
                                        
                                        State / Province / Region
                                      
                                    
                                    ZIP / Postal Code
                                
                                        
                                        Country
                                    
                    
                
Delivery Address    
                    
                         
                                        
                                        Street Address
                                    
                                        
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Medical Information
Medical Aid Provider
e.g. Discovery, Momentum, or None
Current Medications
List any medications you are currently taking, or type None
Known Allergies
e.g. Penicillin, or None
Describe your condition and symptoms(Required)
How long have you had this condition? What have you tried so far?
Have you used cannabis before?(Required)
Consent
Consent(Required) I understand that the doctor may prescribe an unregistered medicine and you have my informed consent that I want to receive it! I consent to my personal and medical information being used for the purposes of this consultation, in accordance with the Cannabis Clinics Privacy Policy and POPIA.(Required)
Consent(Required) By proceeding, you acknowledge that Cannabis Clinics, IntroCann and Greenways Dispensary are associated companies and may contact you as part of your Section 21 application process. [Read our privacy policy](Required)

Condition	—
Doctor	—
Date & Time	—
Consultation fee	R 450.00
SAHPRA application fee	R 400.00
Total	R 850.00





	
		
		
			
			
				
				
				
				
					
				
				
					
				
			
		
		
			
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