Patient Application Form

Welcome to the Veteran Access Scheme.

This form is for Prescribers (General Practitioners) to fill in on behalf of their patients.

Please do not fill in this form if you are a patient.

If you require recommendations for a local doctor please contact us.

Prescribing Doctor Details

Doctor's First Name *

Doctor's Last Name *

Doctors email *

Clinic Phone Number *

Patient Details

Patient First Name *

Patient Last Name *

Date of Birth *

DVA Card Type *

DVA Number *

Address *

Street addressStreet address line 2

City

State

Postcode

Patient Phone Number *

Patient Email Address *

DVA Recognised Conditions *

Pathway Nomination *

Does this Pathway A nomination include DVA Tier 2 Products *

List DVA Tier 2 Products *

Provocatus THC26 - 60ml - CAT 4 oilProvocatus Coastal Rosemary THC 26% (Indica dominant) - 10g - CAT 5 dried flowerProvocatus Illawarra Flame Tree THC 21% (Sativa dominant) 10g - CAT 5 dried flower

Supporting Documentation

Special Access Scheme (SAS) / Authorised Prescriber Documents *

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Copy of Pain Specialist Referral (not required for Pathway B)

Browse

Copy of Script *

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For Pathway A include both Tier 1 and Tier 2 products

Patient Health Summary *

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Patient Preferred Pharmacy *Patient's clinic to ensue eScripts are sent to the nominated Pharmacy

Patient Preferred Pharmacy (Other)

* By submitting this application, the veteran agrees to be contacted by a program representative to:

Complete a short questionnaire 6 months after treatment commencement to facilitate the optimisation of this program.
Discuss and potentially enter a 12 month patient study aimed at developing data associated to Medicinal Cannabis use by Australian Veterans.

Application complete *

YesNo

Comments *

Attachments correct *

YesNo

Comments *

Project documentation complete (VAS CRM and Project Management Reference Document completed) *

YesNo

Comments *

Dispensing Pharmacy *Patient's clinic to ensue eScripts are sent to the nominated Pharmacy

Other Nominated Pharmacy

Application Approved *

YesNo

Comments *

VAS Project Officer *

Signature *

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Date Approved *

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