Health Care Practitioner Package
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
Health Care Practitioner Package
Included in this package
• Medical Document: Include full name and address of the Health Care Practitioner (HCP), and the
details of the Applicant's prescription.
• Consent to Disclose Personal Health Information: This form demonstrates the HCP has
permission to share the Applicant's medical marijuana dose information with CanniMed Ltd.
CanniMed staff will contact the HCP's medical office to confirm dose information on the Medical
Document.
Health Care Practitioner (HCP)
1. Keep original Consent to Disclose
Personal Health Information.
Send photocopy to CanniMed Ltd.
2. HCP or the Applicant sends
original Medical Document to
CanniMed Ltd.
** HCP keeps a photocopy of the Medical **
Document for dose verification
Applicant/Patient
1. Complete Form A, B, or C. Send
to CanniMed Ltd.
2. Applicant or HCP sends original
Medical Document to CanniMed
Ltd.
CanniMed Ltd. staff will
contact the medical office to
confirm the Applicant's dose.
HCP keeps Consent to Disclose
Personal Health Information
so that dose information can
be confirmed by medical office
administrative staff.
Electronic Forms
Fillable PDF forms can be downloaded at http://cannimed.ca/pages/application-forms-and-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.
Health Care Practitioner Package
Version 2.3 - August 2014 © CanniMed Ltd.
Page 1 of 3
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
Province licensed to practice
Clinic/Business name
Unit #
Street address
City
Postal code
Province
Telephone #
Fax #
Email address
Address of consultation (If different from business location)
Unit #
Optional
Same as location above
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
Available
October 2014
1·13
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
Health Care Practitioner Package
MM/DD/YYYY
Version 2.3 - August 2014 © CanniMed Ltd.
Page 2 of 3
Consent to Disclose Personal Health Information
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 - Applicant information and declaration
Applicant
Given Name(s)
Unit #
Surname
Street address
City
Province
Postal code
Home telephone #
Work telephone #
or
I,
Applicant
Substitute decision maker*
authorize
to disclose my personal health information, consisting of medical
Health care practitioner
marijuana dose information, to CanniMed Ltd. CanniMed Ltd. will verify dose information with the Health Care Practitioner.
I understand the purpose for disclosing this personal health information to CanniMed Ltd. I understand that I can refuse to sign this
consent form.
Applicant, or substitute decision maker
(individual responsible) signature
Date
MM/DD/YYYY
*Note: A substitute decision maker is a person authorized under the Health Information Protection Act, 2005 (HIPA) to consent, on
behalf of an individual, to disclose personal health information about the individual.
Part 2 - Witness information and declaration
Witness name
Given name(s)
Unit #
Surname
Street address
City
Province
Home telephone #
Work telephone #
Date
Witness signature
Consent to Disclose Personal Health Information
Health Care Practitioner Package
Postal code
MM/DD/YYYY
Version 2.3 - August 2014 © CanniMed Ltd.
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