Customer Onboarding

Please read carefully and fill in all details below and sign and submit the completed form.

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Upload your completed form*

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Please upload your fully completed Onboarding Form

Pharmacy Details

Pharmacy Name*

(As stated on Registration)

Pharmacy ABN*

Pharmacy Address

(As stated on Registration)

Pharmacy Street*

Pharmacy Suburb*

Pharmacy State*

Pharmacy Postcode*

Postal Address

My postal address is different

Postal Address

(if different from Pharmacy Address)

Postal Street*

Postal Suburb*

Postal State*

Postal Postcode*

Proprietor Details

Proprietor Name*

Proprietor Phone*

Proprietor Email

Proprietor AHPRA Registration Number*

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Upload AHPRA registration number and Pharmacy registration document

Accepted file types: jpg, gif, png, pdf, Max. file size: 1,000 MB.

Please provide a copy of the pharmacy registration document (this document must enclose the expiry date) or a copy of the AHPRA Registration Number (in the same name as the Medicare agreement)

Upload AHPRA registration number and Pharmacy registration document*

Drop files here or

Max. file size: 1,000 MB.

Please provide a copy of the pharmacy registration document (this document must enclose the expiry date) or a copy of the AHPRA Registration Number (in the same name as the Medicare agreement).

Pharmacist in charge

Pharmacist in charge is different to proprietor

Pharmacist in charge details

(if different to above)

Pharmacist in charge details Name*

Pharmacist in charge details Phone*

Pharmacist in charge details Email

Pharmacist in charge details AHPRA Registration Number*

Upload AHPRA Registration Number*

Accepted file types: jpg, gif, png, pdf, Max. file size: 1,000 MB.

Please provide a copy of the pharmacy registration document (this document must enclose the expiry date) or a copy of the AHPRA Registration Number (in the same name as the Medicare agreement)

Upload Pharmacy Licence*

Accepted file types: jpg, gif, png, pdf, Max. file size: 1,000 MB.

Please provide a copy of the pharmacy licence

CREATE YOUR PASSWORD

Password*

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Onboarding Checklist

For pharmacies provided with a pharmacy registration document

Onboarding checklist*

All authorised persons above have attached a copy of their AHPRA registration.

A copy of the pharmacy registration document is attached - the expiry date must be indicated on the document.

Name

This field is for validation purposes and should be left unchanged.

Terms and Conditions

Accounts are approved on the receipt of the customer onboarding form and relevant registration documents.
For applicable states a copy of the state S8 authority approval must be supplied as per table 1 below.
For all required orders customers are required to fill out the Cannim Order Form.
All Order Forms are to be emailed to orders@cannim.com.
A Confirmation Form will be emailed to the email address provided above once the order has been processed.
On receipt of the goods, the Confirmation Form will need to be signed and dated as proof of order and
receipt and emailed to orders@cannim.com within 7 days of receipt.
Orders cannot be processed without the receipt of a SAS-Cat B / Authorised Prescriber (AP) or CTN/CTA authorisation approved by the TGA showing the following.
- Substances
- Quantities.
- Supply Points (where stated)
- Any restriction and/or conditions.
All products are only supplied in their original packaging to the registered business address.
I understand that as the Authorised Person, it is my responsibility to ensure all stock holdings at the Dispensary are in compliance with the relevant and applicable laws and regulatory guidelines.
I will not permit any other persons to order and receive product on my behalf
All provided registration details will be verified through the AHPRA portal.

Payment Terms

An invoice will be sent with for each order received and processed.
A monthly statement will be sent with a summary of all the orders for that month.
All invoices are required to be paid in full within 30 days of receiving the invoice.
No further orders will be processed if there are outstanding invoices on the account.

Customer Service

For all enquires, product information, complaints and returns please contact service@cannim.com.
For any Adverse Drug Reaction, please immediately contact Cannim Australia on (02) 9976 2467.

Table 1

For applicable states (s8 supply) the following state approval must be supplied upon ordering

NSW

Approval to Prescribe and Supply a Schedule 8 Cannabis Medicine for Human Therapeutic Use authorisation when prescribing to

a drug dependent person (including a person treated under the Opioid Treatment Program), or
a child aged under 16 years of age

Approval for Authority to Prescribe and Supply a Substance for the Purpose of Human Research authorisation for CTN/CTA (Clinical Trial) authorisation.

ACT

ACT Chief Health Officer approval form

VIC

Schedule 8 Permit when prescribing to a drug dependent person

QLD

A Request for Chief Executive Approval form when prescribing to a patient considered as drug dependent person

A section 18A authority to prescribe a medicinal cannabis product that is a Schedule 8 controlled drug (drug of dependence)

TAS

Application to prescribe under Section 59E of the Poisons Act 1971

Customer Onboarding

Pharmacy Details

Pharmacy Address

(As stated on Registration)

Postal Address

(if different from Pharmacy Address)

Proprietor Details

Pharmacist in charge details

(if different to above)

CREATE YOUR PASSWORD

Onboarding Checklist

Terms and Conditions

Payment Terms

Customer Service

Table 1

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