FINANCIAL ASSISTANCE FORM

Street Address Line 1

Street Address Line 2

Suburb

State/Territory

Postcode

For which indication are you being prescribed Medicinal Cannabis?* (Select All that Apply)

If other, please specify

Why is access to affordable medicinal cannabis important to you?

Clinic or Prescriber Details

Clinic Name

Prescriber’s Name

Contact Number

Email Address

Have you discussed this financial support with your prescriber?

Do you consent to Stanley Brothers contacting your prescriber/clinic to discuss compassionate access?

Is your clinic/prescriber willing to send your prescription to our partner pharmacy?

Do you hold any of the following concession or healthcare cards:

Customer Reference Number (CRN)

Date your concession entitlement begins

Date it expires

Relationship Status:

Dependants

Weekly Income Before Tax (Combined if Married, De Facto, Civil Partnership)

I am happy to receive any updates

I have read and agreed to the Privacy Policy and Terms of Service

*= Required Field