Compassionate Access Form Pine Dispensary

Acacia Care Eligibility Pine Dispensary

Full Name *

Date of Birth *

Email *

Phone *

Address *

Medicare Number *

Upload Photo of Medicare Card

Maximum file size: 134.22MB

Please add photo ID (Drivers Licence or Passport)

Maximum file size: 134.22MB

Are you an Acacia New or Review patient ?

Yes

Do you currently hold a valid Centrelink Health Care Card, Pensioner Concession Card, Student Card ? *

Yes

Please upload a photo of your Centrelink Health Care Card, Pensioner Concession Card, Student Card

Maximum file size: 134.22MB

Are you experiencing financial hardship that affects your ability to afford Medical Cannabis ? *

Yes

Are you of Aboriginal or Torres Strait Islander ? *

Yes

Do you hold a Department of Veterans' Affairs (DVA) Card? *

Yes

Please upload a photo of your Department of Veterans' Affairs (DVA) Card

Maximum file size: 134.22MB

Are you receiving support from any government or community-based assistance programs? *

Yes

Please provide a brief summary of your current financial situation and why you are applying for compassionate access. *

I confirm that all information provided is true and accurate to the best of my knowledge.

I understand that Acacia Medical may use this information to assess my eligibility for the Compassionate Access Program.

If you are human, leave this field blank.

ACACIA INFORMATION

ACN: 660 687 525

Queensland Time Australia Wide

Enquiries Email Receptionist
M-F 9am-4.30pm E: [email protected]

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