Medical Document Toll-free: 1-855-787-1577 [email protected] www.cannimed.ca Please mail or courier documents to: #1 Plant Technology Road Box 19A, RR#5 Saskatoon, SK S7K 3J8 Physician: 1. Completes and signs the Medical Document 2. Sends the original Medical Document to CanniMed Ltd. by mail or courier* 3. Keeps a photocopy of the Medical Document to verify the dose Applicant/Patient: 1. Completes and signs Application Form A, B, or C. 2. Sends the Application Form to CanniMed by fax, email, courier or mail. 3. A scan of the signed Application form will be accepted Once the Application Form and Medical Document are received, CanniMed Ltd. staff contact the medical office to confirm the Applicant's dose. The applicant becomes a registered CanniMed patient after verification from the medical office is received. * The Medical Document and Application Form can be sent to CanniMed by either the applicant or the physician, and can be sent together or separately. Electronic Forms Fillable PDF forms can be downloaded at http://cannimed.ca/pages/application-formsand-medical-document or requested from CanniMed Customer Service by email at [email protected] or toll-free at 1-855-787-1577. Please note: Even with electronic forms we require an original ink signature on the Medical Document. Medical Document Version 3 - April 2015 © CanniMed Ltd. Page 1 of 2 Medical Document Toll-free: 1-855-787-1577 [email protected] www.cannimed.ca Please mail or courier documents to: #1 Plant Technology Road Box 19A, RR#5 Saskatoon, SK S7K 3J8 Part 1 - Health Care Practitioner information Name Title Given name(s) Surname Profession Medical licence number - Identify your licensing province if different than that of your clinic Clinic/Business name Unit # Street address City Postal code Province Telephone Fax Ext. Email Optional Address of consultation (If different from business location) Unit # Street address City Postal code Province Part 2 - Patient information Name Date of birth Given name(s) MM/DD/YYYY Surname Part 3 - Product restrictions Please choose which product(s) your patient may order (leave all boxes unchecked to allow your patient full product choice): 22·1 17·1 15·5 12·0 9·9 4·10 1·13 CanniMed Starter Program (Includes CanniMed 17·1, 9·9, 4·10, and the Arizer Air vaporizer) TM Part 4 - Authorization Medical diagnosis (optional) The Applicant may access grams of medical marijuana per day for months. Note: Applicant can possess a maximum of 150g or 30 times their daily amount, whichever is less. Under the Marihuana for Medical Purposes Regulations, maximum authorization is a period of 12 months and begins the day the Medical Document is signed by the HCP. I, Printed name of Health Care Practitioner attest that the information contained in this document is correct and complete. Date Health Care Practitioner's signature Medical Document MM/DD/YYYY Version 3 - April 2015 © CanniMed Ltd. Page 2 of 2