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Under the Marihuana Medical Access Regulations, a "medical practitioner" is a person who is authorized under the laws of a province to practice medicine in that province and who is not named in a notice given under sections 58 or 59 of the Narcotic Control Regulations.
If you have any questions regarding this form, please contact Health Canada toll-free at 1-866-337-7705.
Please forward all completed applications to:
Marihuana Medical Access Division
Drug Strategy and Controlled Substances Programme
Address Locator: 3503B
Ottawa, ON K1A 1B9
Note: It is within the professional purview of the medical practitioner to decide to support an application to access marihuana for medical purposes. A medical practitioner is not obliged to sign in support of an application.
B1-1 Information on Medical Practitioner
B1-2 Medical Condition and Symptoms
Please check () in the table below the medical condition(s) and the symptom(s) that are the basis for the application (if applicable).
|CACHEXIA||ANOREXIA||WEIGHT LOSS||SEVERE NAUSEA||SEIZURES|
|AIDS , HIV INFECTION|
B1-3 The Proposed Daily Amount
Health Canada's examination of the current available information suggests most individuals use an average daily amount of 1 gram to 3 grams of dried marihuana for medical purposes, whether it is taken orally, or inhaled or a combination of both.
Note to Physicians: For more information on daily amounts, you can refer to the following documents:
Both documents can be found on the Health Canada Web site at http://hc-sc.gc.ca/dhp-mps/marihuana/index-eng.php or by calling toll free at 1-866-337-7705.
Under the Marihuana Medical Access Regulations, an Authorization to Possess may be issued for a period of up to 12 months.
If you are signing the authorization for a shorter period, please specify the number of months:
B1-5 Medical Practitioner's Declaration and Signature
Please read, sign and date the document in the space provided below.
If you have questions regarding this form, please contact Health Canada toll-free at 1-866-337-7705.