- see “cannabinoids“
Prescription Guides of cannabis-based magistral preparations
for THC >1% , prescribers must submit a request to the Federal Office of Public Health FOPH
SUBJECT: REQUEST FOR EXCEPTIONAL AUTHORISATION FROM THE FOPH FOR THE PRESCRIPTION OF PROHIBITED NARCOTICS (OF THE CANNABIC TYPE) FOR LIMITED MEDICAL USE
I hereby submit an application for authorisation to prescribe medication containing the active substance -9-tetrahydrocannabinol (THC) to the patient named below.
1 APPLICANT PHYSICIAN
First name E-mail
Postal code / Place Place/ date
I hereby confirm that
- I have entered the data correctly.
- To draw up and submit to the FOPH an interim report every 6 months on the progress of the treatment and a final report.
Name Street/ No.
First name Postcode / Place
Date of birth
DECLARATION OF CONSENT BY THE PATIENT
I hereby confirm that I have had an information interview with the doctor, that I have been informed about the financial arrangements and that I agree to the treatment with a cannabis preparation.
Name / First name
3 MEDICAL FILE
Therapy taken so far (specific medication), course of therapy
Justification for treatment with a cannabis preparation
THC: -9-tetrahydrocannabinol, CBD: Cannabidiol
- Isolate “1/0” THC solution, dronabinol 2.5% THC 5% THC 10% THC
- Isolate “1/2” THC/CBD solution: Standardized cannabis oil (~10 mg THC/ ml and ~20 mg CBD/ ml)
- Isolate “1/1” THC/CBD solution*: Standardized cannabis oil (~27 mg THC/ ml and ~25 mg CBD/ ml)
- Full Spectrum THC/CBD solution, 2.5% THC 5% THC 10% THC / CBD 2.5%
- Full Spectrum CBD/THC solution, at 2.5% CBD 5% CBD 10% CBD / THC 2.5%
- Tailor-made: %THC / %CBD (total THC+CBD = max 20%)
Person responsible E-mail
Postal code / Place
Street / N°
Postal code / Location
7 ADDITIONAL INFORMATION
Expiry of authorisation: A new application for treatment must be submitted at the latest two weeks before the expiry of the authorisation, accompanied by an interim report on the progress of the treatment.
Interruption/end of treatment: Any interruption of treatment must be announced and briefly justified (death, unsatisfactory effects, side effects, etc.).