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Application for Authorization to Possess Marihuana for Medical Purposes - Form B1

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Form B1- Medical Practitioner's Form for Category 1 Applicants

This form is to be completed for Category 1 applicants by the applicant's medical practitioner.

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.

Important

  1. It is important to understand that all information requested must be provided to avoid unnecessary delays.
  2. We cannot process the application until all appropriate forms are received.
  3. Please retain a photocopy of this form for your files.

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
Health Canada
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

  • Medical practitioner's full name:
  • Provincial medical licence number:
  • STAMP (if available)
  • Medical specialization (if applicable):
  • Business Address:
    • Suite Number:
    • City:
    • Province:
    • Postal Code:
  • Telephone: ()
  • Fax: ()
  • E-mail:

B1-2 Medical Condition and Symptoms

  • Applicant's full name:
    • last
    • first
    • middle
  • Date of Birth:
    • year
    • month
    • day
  • Telephone: ()

Please check (check mark) in the table below the medical condition(s) and the symptom(s) that are the basis for the application (if applicable).

Details on medical condition(s) and symptom(s)
  SEVERE PAIN PERSISTENT
MUSCLE SPASMS		 CACHEXIA ANOREXIA WEIGHT LOSS SEVERE NAUSEA SEIZURES
MULTIPLE SCLEROSIS              
SPINAL CORD
INJURY		              
SPINAL CORD
DISEASE		              
CANCER
 		              
AIDS , HIV INFECTION              
SEVERE ARTHRITIS              
EPILEPSY
 		              

OR

  • If the applicant is treated within the context of compassionate end-of-life care, please specify the medical condition(s) and the symptom(s):
  • Medical Condition(s) and Symptom(s):

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.

  1. The proposed daily amount of dried marihuana is less than or equal to grams (use letters to write amount); and
  2. the following method and form of administration (please check appropriate box):
    • Inhalation
    • Oral

Note to Physicians: For more information on daily amounts, you can refer to the following documents:

  • Information for Health Care Professionals -- Marihuana
  • Daily Amount Fact Sheet

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.

B1-4 Duration

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.

    1. The applicant suffers from the Category 1 symptom(s) indicated in Section B1-2 of this form that is associated with the corresponding medical condition or the medical treatment that is associated with that condition;

    2. conventional treatment(s) for the Category 1 symptom(s) have been tried or considered, and have been found to be ineffective or medically inappropriate for the treatment of the applicant.

  2. I am aware that a Notice of Compliance has not been issued under the Food and Drug Regulations concerning the safety and effectiveness of marihuana as a drug.

  3. I declare that the information contained in this form is correct and complete.
  • MEDICAL PRACTITIONER'S SIGNATURE
  • PRINT NAME
  • DATE

Important:

  1. Please ensure that you have read and understood the declarations.
  2. Please sign and date the declarations.
  3. It is important to understand that all mandatory information requested must be provided to avoid unnecessary delays.
  4. We cannot process the application until ALL appropriate forms are received.
  5. Please retain a photocopy of this form for your files.

If you have questions regarding this form, please contact Health Canada toll-free at 1-866-337-7705.

Table of Contents
Date Modified: 2011-06-17

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