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This document may be completed by the applicant's authorized health care practitioner as defined in the Marihuana for Medical Purposes Regulations. An authorized health care practitioner includes physicians in all provinces and territories, and nurse practitioners in provinces and territories where prescribing dried marihuana for medical purposes is permitted under their scope of practice. If another document is used, it must contain all of the information below.
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:
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):