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    Medical Document Supporting The Use of Cannabis For Medical Purposes Under The Cannabis Regulations

    Uploaded by

    Am M
    This 3 sentence summary provides the key details from the medical document: The document is to be completed by a healthcare practitioner to authorize a patient's use of cannabis for medical purposes under the Cannabis Regulations. It requires information about the patient, the daily quantity of cannabis authorized, and the period of authorized use. The healthcare practitioner must sign and date the document to attest that the information is correct and that they are eligible to authorize cannabis use.

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    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd

    Medical Document Supporting The Use of Cannabis For Medical Purposes Under The Cannabis Regulations

    Uploaded by

    Am M
    12 views2 pages
    This 3 sentence summary provides the key details from the medical document: The document is to be completed by a healthcare practitioner to authorize a patient's use of cannabis for medical purposes under the Cannabis Regulations. It requires information about the patient, the daily quantity of cannabis authorized, and the period of authorized use. The healthcare practitioner must sign and date the document to attest that the information is correct and that they are eligible to authorize cannabis use.

    Original Title

    MedicalDocumentEN

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    This 3 sentence summary provides the key details from the medical document: The document is to be completed by a healthcare practitioner to authorize a patient's use of cannabis for medical purposes under the Cannabis Regulations. It requires information about the patient, the daily quantity of cannabis authorized, and the period of authorized use. The healthcare practitioner must sign and date the document to attest that the information is correct and that they are eligible to authorize cannabis use.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    12 views2 pages

    Medical Document Supporting The Use of Cannabis For Medical Purposes Under The Cannabis Regulations

    Uploaded by

    Am M
    This 3 sentence summary provides the key details from the medical document: The document is to be completed by a healthcare practitioner to authorize a patient's use of cannabis for medical purposes under the Cannabis Regulations. It requires information about the patient, the daily quantity of cannabis authorized, and the period of authorized use. The healthcare practitioner must sign and date the document to attest that the information is correct and that they are eligible to authorize cannabis use.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 2

    Medical document supporting the use of cannabis for

    medical purposes under the Cannabis Regulations


    Instructions
    This document may only be completed by a health care practitioner as defined in the Cannabis
    Regulations. A health care practitioner includes medical practitioners and, in some provinces, nurse
    practitioners. In order to be eligible to provide a medical document, the health care practitioner must be
    eligible under the Cannabis Regulations, have the applicant for whom the medical document is
    provided under their professional treatment, and support that cannabis is required for the condition for
    which their patient is receiving treatment.

    Patient’s Information
    Personal Information of Patient
    Patient’s Last Name:

    Patient’s First Name: Patient’s Middle Name(s):

    Patient’s Date of Birth: Year Month Day

    Consultation Information
    Daily quantity of dried cannabis authorized for the patient: Grams/Day
    Authorized period of use: Day(s)
    (Note: The period of use cannot exceed one (1) year) Week(s)
    Month(s)

    Health Care Practitioner’s Information


    Health Care Practitioner’s First and Last Name:

    Health Care Practitioner’s Licence Number (if more Province or territory authorized to practice in (if more
    than one list all that apply): than one list all that apply):

    Profession: Medical Practitioner Nurse Practitioner


    Health Care Practitioner’s Business Address:
    2 | Medical Document Authorizing the use of Cannabis for Medical Purposes under the Cannabis Regulations

    Business Address of Medical Consultation with Patient (if different than above):

    Telephone Number: Fax Number:

    Email Address (if applicable):

    By signing this document, the health care practitioner is attesting that they are not restricted, under
    the laws of the province or territory in which they practice, from authorizing the use of cannabis,
    and that the information contained in this document is correct and complete.
    Health Care Practitioner's Signature: Signature Date:

    Sending a Medical Document

    There are two scenarios where a health care practitioner may send a medical document by secure fax and
    have it recognized as an original:

    • If your patient chooses to access cannabis for medical purposes via a federally-licensed seller, this
    medical document can be submitted from your office to the licensed seller by secure fax; or

    • If Health Canada contacts your office requesting a medical document as part of an application
    received from your patient for the production or possession of cannabis for medical purposes.

    If you choose to submit the medical document by secure fax under one of the above scenarios, please
    initial the appropriate statement below to acknowledge agreement. If these scenarios do not apply,
    please leave this section blank and simply provide the original medical document to your patient.

    Please select only one of the following options if sending the medical document by secure fax:

    By initialling this box, I, the supporting health care practitioner, have been asked by my patient
    to send this medical document directly to a licensed seller. In sending it by fax, I
    acknowledge that the faxed medical document shall constitute the original medical document.

    By initialling this box, I, the supporting health care practitioner, have been asked by Health
    Canada to submit to them directly a new medical document as part of my patient’s application
    for the production or possession of cannabis for medical purposes. In sending it by fax, I
    acknowledge that the faxed medical document shall constitute the original medical document.

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