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Prescribers


      Scientifc Informations

      Prescription Guides of cannabis-based magistral preparations

      Practical Informations

      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

      Dear Sir/Madam,

      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

      Name Telephone
      First name E-mail
      Street/ No.
      Postal code / Place Place/ date

      I hereby confirm that

      Place/ date

      Signature of
      Attending physician

      2 PATIENT

      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

      Date Signature

      3 MEDICAL FILE

      Diagnosis

      Therapy taken so far (specific medication), course of therapy

      Justification for treatment with a cannabis preparation

      4 PRESCRIBING

      THC: -9-tetrahydrocannabinol, CBD: Cannabidiol

      5 PHARMACY

      Pharmacy Phone
      Person responsible E-mail
      Street/ No.
      Postal code / Place

      6 PRODUCTION

      Laboratory Name
      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.).

      Official Website of the Federal Office of Public Health FOPH

      Application médicale limitée de stupéfiants interdits (p. ex. le «cannabis», THC)
      Beschränkte medizinische Anwendung von verbotenen Betäubungsmitteln (Cannabis, THC)
      Applicazione medica limitata di stupefacenti vietati (p. es. canapa, THC)
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