Disability Allowance GP Form

For patients – if you are already on a disability allowance, please ask your GP to fill in the form below online (or print out a copy here and take it with you to your next appointment). This form must be completed by your GP before we can apply to the Ministry of Social Development for additional funding on your behalf.

For doctors – please provide information about your patient in the form below so we can apply to the Ministry of Social Development on their behalf. Alternatively, print out the form here and fill it in.

"*" indicates required fields

DOCTOR INFORMATION

Doctor's Name*

Doctor's Email Address*

Doctor's Contact Number*

Practice Name*

PATIENT INFORMATION

Patient's Full Name*

NHI Number (if known)

MSD (WINZ) Client Number*

Patient's Address*

Medical Reason for Medicinal Cannabis*

Patient's Other Medications*

As the patient's GP, I confirm:*

I support the use of medicinal cannabis for my patient.

I believe that medicinal cannabis may benefit my patient.

I refer my patient to the Cannabis Clinic for all matters specifically related to medicinal cannabis.

I believe there is a high likelihood that Pharmac will decline funding for this named patient.

I would like to receive email updates from the Cannabis Clinic.

Signature/Initials*

Date of Submission*

Disability Allowance GP Form

DOCTOR INFORMATION

PATIENT INFORMATION

Terms & Conditions

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Request & Purchase Your Medication

Already have a script from your GP?

Terms & Conditions - Dispensary

Already have a script from your GP?

Terms & Conditions - Dispensary

Disability Allowance GP Form

DOCTOR INFORMATION

PATIENT INFORMATION

Book a Consultation

Terms & Conditions

Learn more

Book Now Refresh Page

Request & Purchase Your Medication

Already have a script from your GP?

Terms & Conditions - Dispensary

Already have a script from your GP?

Terms & Conditions - Dispensary

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