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Drugs and Health Products

Sample Medical Document for the Access to Cannabis for Medical Purposes Regulations

Help on accessing alternative formats, such as Portable Document Format (PDF), Microsoft Word and PowerPoint (PPT) files, can be obtained in the alternate format help section.

For related information, please see Health Canada's Information for Health Care Practitioners.

This document may be completed by the applicant's health care practitioner as defined in the Access to Cannabis for Medical Purposes Regulations (ACMPR). A health care practitioner includes medical practitioners and nurse practitioners. In order to be eligible to provide a medical document, the health care practitioner must have the applicant for the medical document under their professional treatment. Regardless of whether or not this form is used, the medical document must contain all of the required information, (see in particular s. 8 of the ACMPR).

Patient's Given Name and Surname:
Patient's Date of Birth (DD/MM/YYYY):
Daily quantity of dried marihuana to be used by the patient: _ g/day

The period of use is ____day(s) _____week(s) _____month(s).

NOTE: The period of use cannot exceed one year

Health care practitioner's given name and surname:
Profession:
Health care practitioner's business address:
Full business address of the location at which the patient consulted the health care practitioner
(if different than above):

Phone Number:
Fax Number (if applicable):
Email Address (if applicable):

Province(s) Authorized to Practice in:
Health Care Practitioner's Licence number:

By signing this document, the health care practitioner is attesting that the information contained in this document is correct and complete.

Health Care Practitioner's Signature:
Date Signed (DD/MM/YYYY):


NOTE: The medical document can be submitted from the health care practitioner's office to the licensed producer by secure fax. If you choose to submit the medical document by secure fax, initial the statement below to acknowledge agreement.

I, the health care practitioner, acknowledge that the faxed medical document is now the original medical document and that I have retained a copy of this document for my records only.

Initial here: