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).
Your health care practitioner may use this form to provide you authorization to use cannabis for medical purposes. Your health care practitioner may use a different form, but the required information as per section 8 of the ACMPR (outlined below) must be included.
Access via Health Canada licensed producers: Should you choose to access cannabis from a licensed producer, this form must be sent directly to the licensed producer of your choice. You may choose any licensed producer who is authorized to sell to registered clients. Please see the Health Canada website for a list of licensed producers. Should you wish to switch from one Health Canada licensed producer to another a new medical document will be required as licensed producers are required to keep the original medical document on file.
Access via production for own medical purposes: Should you choose to produce your own cannabis, or designate someone to produce it for you, the original of this document must be sent to Health Canada with your Registration Application Form.
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: grams / 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:
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):
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):
If the patient chooses to produce cannabis for their own medical purposes or you are not submitting this document via secure fax do not initial the box below.
If your patient chooses to access cannabis for medical purposes via a licensed producer, this 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.