Patient Registration

About 8–10 minutes · works best on your phone

Your personal details

Already a member? Enter your membership number to pre-fill your details.

Membership number (optional)

* Title

* First name

* Surname

* Identification type

* ID number

Date of birth

Age

Weight (kg)

Height (cm)

* Gender

* Occupation

* Phone

* Email Address

Address & dispensary

Start typing your address to search, or enter it manually below.

* Address line 1

Address line 2

* City

* Postal code

Country

* Preferred dispensary

Identity documents

JPG or PNG, max 5 MB each. Use your phone camera for clearest photos.

* Front of ID / passport

Back of ID (optional)

* Selfie photo

Emergency contact

* Name

* Relationship

* Phone number

Create your password

* Password

At least 6 characters
One uppercase letter
One lowercase letter
One number

* Repeat Password

Medical Cannabis Use:

* Have you previously used cannabis for medical purposes?

If yes, please describe your experience.

* What condition are you aiming to treat with medical cannabis?

*Have you experienced any adverse reactions from cannabis use in the past?

If yes, please describe:

Cannabis Use History:

* Have you used cannabis before?

If yes, please describe your experience:

Informed Consent

Informed Consent Form

I, , voluntarily agree to be treated with a medication, namely THC & CBD, which is not registered in South Africa, by Dr. Jordan Ochayon for .

I confirm that I have been fully informed and my questions answered by Dr. Jordan Ochayon about my disease (for which a section 21 application is being made), its cause, severity, prognosis, available (in South Africa) registered treatment options and the reasons for the current state of my illness and the unregistered medication and application to use a medication that is not registered in S.A., and that:

I will be free to stop using the medication at any time and that I will inform my Dr. Jordan Ochayon (treating doctor) accordingly.

Patient Declaration & Signature

Declaration

1. I am over the age of 18 years old.
2. I am not addicted to habit-forming substances, including controlled substances.
3. I am not engaged in the illegal buying, selling, or dealing of any restricted or controlled substances.
4. I understand that any information or materials provided to me are intended for legal and informational purposes only.
5. I acknowledge that any use of substances, materials, or information obtained through this channel is at my own risk, based upon the prescription from my traditional healer and I will adhere to script and all applicable laws and regulations.
6. I shall not resell any of the items received in terms of the script for medical cannabis, as it is intended for my personal medical used only.
7. I understand that this confirmation is a material representation upon which reliance is placed, and any false statements may lead to legal consequences.

I hereby declare that the information provided in this questionnaire is accurate and complete to the best of my knowledge. I understand the importance of disclosing my medical history for the purpose of receiving appropriate medical cannabis recommendations.

Signed at *

on 2026-05-30

Name ID Number

* Signature

Signature Accepted