Methadone Exemption Application

(For physicians practicing in the province of Ontario and applying for an exemption for analgesic purposes)

1. Identification

• Applicant:
  • Physician
  • Veterinarian
  • Dentist
• Surname:
• Given Name:
• Licence(s):
• Specialty:
• Post Graduate Training:
• Primary Practice:
  • Address:
  • Institution:
  • Street:
  • Room:
  • City:
  • Province: Ontario
  • PostalCode:
• Telephone:
• Fax:
• E-mail Address:
• Mailing Address: (if different from above):
• Language
  • English
  • Français

2. Exemption

• Indication: Analgesia
• Type:
  • New
  • Renewal
  • Cancellation
• Other:
  • For one patient only
    • name of patient:
  • Correctionnal Services

3. Qualifications and Experience

• Describe qualifications and experience with methadone for pain:
• Type of practice ( solo or group):
• Name of consultant*

*Consultant: Name of a physician who is already exempted to prescribe methadone for analgesic purposes and has agreed to be available to answer your questions when necessary during the first year methadone prescribing.

4. Declaration

By, this and under the condition that the released information is treated confidentially, I consent to the release from the licensing authority of the province or provinces in wich I am registered and entitled to practice, to the Office of Controlled Substances of information from my personal file pertaining to the review of my application to prescribe methadone or to any other action related to this request for an exemption

Please send the application to the address below:

Methadone Programme
Evaluation and Authorization Division
Office of Controlled Substances
Health Canada
2^nd Floor
123 Slater St
AL 3502B
Ottawa ON K1A 1B9

A copy of the application may be faxed to (613) 952-8576, however, the original must be sent by mail. For further information, please contact the Evaluation and Authorization Division at (613) 946-5139 or toll free 1-866-358-0453, by fax at (613) 952-8576 or by e-mail at exemption@hc-sc.gc.ca