Biodata Research Gateway

BIODATA RESEARCH GATEWAY

Kindly take note that Cannafrica will not share your personal information with any third party whatsoever. The reason for the below mentioned information is solely in order to formally register onto our BioData program in order for Cannafrica and its employees to adequately dispense applicable products to you.

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Personal Details

Are you a South African citizen?

Yes No

Title

First Name

Surname

Race

African White Coloured Indian Other

Gender

Male Female Other

Cellphone Number Please enter a valid 10-digit phone number (e.g., 1234567890).

Email Address Please enter a valid email address.

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Identification & Location

ID/Passport Number Invalid ID number. Please check and try again.

Date of Birth

ID/Passport Document

Please upload a clear photo of the front side of your ID or passport.

Upload / Drag & Drop a file

PNG, JPG, PDF up to 10MB

Branch

Country of Residence

Province

Search Province

City of Residence

Search City

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Health History

Age

18-25 26-30 31-40 41-50 51-60 60+

Weight

Height

<1.6 m 1.6-1.7 m 1.7-1.8 m 1.8-1.9 m 1.9-2.0 m 2 m+

Health History

Cancer Pain Anxiety Depression Insomnia Seizures ADHD

Are you on chronic medication?

Yes No

Unfortunately, you cannot be admitted due to chronic medication.

Income

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Submission

Please click for the terms and conditions

By signing this form, I confirm that I have read and understood all terms and conditions of the study and hereby provide my full informed consent. Please provide a signature.

Signature

I accept

Yes No

Unfortunately, you cannot be admitted if you do not consent.

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