The programme is changing. From 1 December 2026 it is managed by Horouta Pharmacy, and the new criteria apply from 1 January 2027. Applications for current and waitlisted patients should be submitted by 1 December 2026.

What would you like to submit?*

New patient enrolment Enrol a patient in the programme, including current or waitlisted patients being reassessed under the new criteria. 6-month reassessment Review ongoing eligibility for an existing programme patient at their six-month review.

I confirm I am a registered medical practitioner or authorised prescriber in Aotearoa New Zealand and am completing this form on behalf of my patient.

Prescriber details

Full name*

Medical registration number*

Practice*

Contact email*

A full copy of this application is sent to this address.

Remember my prescriber details on this device (patient details are never stored)

Patient details

NHI*

Full name*

Date of birth*

Phone*

Address*

Email (optional)

Programme start date*

Review date*

Patient status

Community Services Card holder Palliative patient

Palliative patients do not require a six-month review.

Medicinal cannabis product

Select the product you are requesting for your patient under the programme.

Programme product*

Programme support is provided for one month's supply at a time. The prescription is issued separately by the prescribing doctor directly to the pharmacy. Selecting a product here is not a prescription.

Clinical status

Is medicinal cannabis still clinically appropriate for this patient?*

Yes No

Current clinical outcome*

Improved No change Worsened

Product

Continue current product Request a change

Assessment of eligibilityReassessment of eligibility

Clinical need*

Select the score that best reflects the patient's clinical need for medicinal cannabis.

Clinical indication / reason medicinal cannabis is appropriate*

Financial hardship*

Select the score that best reflects the patient's ability to afford medicinal cannabis.

–/ 15

Priority score Select both scores Clinical need × 2 + Financial hardship

Programme conditions and confirmation

Programme support is subject to ongoing eligibility and review. A six-month review is required unless the patient is palliative. Medication must be collected as arranged, and failure to collect without an agreed reason may result in removal from the programme.

Prescriber confirmation* My patient is a Te Tairāwhiti resident and medicinal cannabis is clinically appropriate. Financial hardship is a significant barrier to access. I have discussed the programme and its conditions with my patient. The information provided is accurate to the best of my knowledge.

Patient consent* I have explained the above to my patient, and they consent to their information being provided to Horouta Pharmacy for the purpose of assessing and administering their application and programme support.

Review outcome

Recommended outcome*

Continue programme support Further review required Exit programme

Comments (optional)

Horouta Pharmacy will contact you to confirm the outcome of the reassessment and whether programme support will continue.

Prescriber confirmation* I confirm that I have reassessed this patient and that the information provided is accurate to the best of my knowledge.

Patient acknowledgement* My patient understands that their eligibility is reviewed every six months and continued support is not automatic, and that medication must be collected as arranged. Failure to collect without an agreed reason may result in removal from the programme.

Declaration

Patient name*

Prescriber name (typed signature)*

Date

Review and submit

Check the details below. Tap Edit to change a section.

Important

This form is used to assess and enrol patients in the Compassionate Access Programme, which is administered by Horouta Pharmacy. Rua Bioscience does not administer the programme and does not receive or hold patient information submitted through this application.

Prescribing is separate from programme enrolment. Selecting a product on this form does not constitute a prescription. Once a patient is approved, the prescribing doctor issues the prescription separately and sends it directly to the pharmacy.

Ngā mihi

Application received

Reference

A full copy of this application has been emailed to .

Horouta Pharmacy will be in contact with you shortly.