CanniMed-Medical-Document.pdf
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1. Completes and signs the Medical Document 2. Sends the original Medical Document to CanniMed Ltd. by mail, courier or secure fax* 3. Keeps a photocopy of the Medical Document to verify the dose #1 Plant Technology Road Box 19A, RR#5 Saskatoon, SK S7K 3J8 Medical Document Medical Document Physician: Applicant/Patient: 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. 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 Fillable PDF forms can be downloaded at http://cannimed.ca/pages/applying-for- medical-marijuana or requested from CanniMed Customer Service by email at [email protected] or toll-free at 1-855-787-1577. The Medical Document must be signed by the physician. If sending by mail, it must include the original ink signature. If sending via fax, it must be sent from the medical office by way of CanniMed Secure Fax. Accessing and submitting forms Page 1 of 2 Version 4 - September 2015 © CanniMed Ltd. * The Medical Document and Application Form can be mailed to CanniMed by either the applicant or the physician, and can be sent together or separately. Faxed forms must be sent from the medical office. See Part 4 for details. Toll-free: 1-855-787-1577 Fax: 1-844-231-8929 [email protected] www.cannimed.ca
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Transcript of CanniMed-Medical-Document.pdf
1. Completes and signs the Medical Document
2. Sends the original Medical Document to CanniMed Ltd. by mail, courier or secure fax*
3. Keeps a photocopy of the Medical Document to verify the dose
#1 Plant Technology Road Box 19A, RR#5
Saskatoon, SK S7K 3J8
Medical Document
Medical Document
Physician:
Applicant/Patient:
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.
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
Fillable PDF forms can be downloaded at http://cannimed.ca/pages/applying-for-medical-marijuana or requested from CanniMed Customer Service by email at
[email protected] or toll-free at 1-855-787-1577.
The Medical Document must be signed by the physician. If sending by mail, it must include the original ink signature. If sending via fax, it must be sent from the medical
office by way of CanniMed Secure Fax.
Accessing and submitting forms
Page 1 of 2Version 4 - September 2015 © CanniMed Ltd.
* The Medical Document and Application Form can be mailed to CanniMed by either the applicant or the physician, and can be sent together or separately. Faxed forms must be sent from the medical office. See Part 4 for details.
Toll-free: 1-855-787-1577 Fax: 1-844-231-8929
[email protected] www.cannimed.ca
I (the Health Care Practitioner) choose to submit the Medical Document via secure fax directly to CanniMed. I acknowledge that the faxed Medical Document is now the original, and the completed form must be kept as a copy in my records. By initialing, I attest that this Medical Document will not be faxed or provided to another Licensed Producer or to the patient.
Medical Document
Part 1 - Health Care Practitioner information
Fax Telephone
Clinic/Business name
Profession
Part 2 - Patient information
Province Postal codeCity
Address of consultation (If different from business location)
Last nameFirst name
Last nameFirst name
The Applicant may access
Part 3 - Physician directions
attest that the information in this document is correct and complete.I,Printed name of Health Care Practitioner
DateHealth Care Practitioner's signature
Medical diagnosis
grams of medical marijuana per day for
Toll-free: 1-855-787-1577 Fax: 1-844-231-8929
[email protected] www.cannimed.ca
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.
MM/DD/YYYY
#1 Plant Technology Road Box 19A, RR#5
Saskatoon, SK S7K 3J8
Postal codeProvinceCity
Street address
Street address
Page 2 of 2
Birthdate
Medical Document Version 4 - September 2015 © CanniMed Ltd.
months.
Part 5 - Authorization
Ext.
Identify licensing province if different than that of your clinic
Part 4 - Fax authorization
Submit Medical Document by secure fax to 1-844-231-8929.
Medical licence number
Default will be full product selection. Please indicate specific instructions below if applicable:
Includes CanniMed® 17·1, 9·9, 4·10 and the ArizerTM Air vaporizerDried cannabis
Cannabis oil
Ie: Begin with the Starter Program then full product choice, Patient may only order cannabis oil products
22·1 17·1 15·5 12·0 9·9 4·10 1·1318:0 10:10 1:20
Starter Program -
For office use onlyVerified by:
Date (time if by phone):
Employee:
MM/DD/YYYY
Health care practitioner initial here if submitting by fax NOTE: Faxed Medical Documents must be received from HCP registered fax number.
Please call 1-855-787-1577 if you have any questions about our Secure Fax service.
