Medical Document To be completed by a Health Care Practitioner. All fields required unless otherwise noted.

Transcription

1 Medical Document To be completed by a Health Care Practitioner. All fields required unless otherwise noted. Patient Information Patient Name Period of Use Month(s) Daily Usage g/day Note: Duration Cannot Exceed One Year Quantity of Dried Marihuana Usage Purpose Primary Condition (Optional) Health Care Practitioner Information Primary Symptom (Optional) Title / Name Title Profession Business Consultation of Consultation Location with Patient (If Different Than Above) Phone / Fax / (Required) (Optional) Jurisdiction / Licence Number (s) Provider is Authorized to Practice In Licence Number By Signing, the Practitioner Attests that the Information In This Document is Correct and Complete TILRAY1( )

2 Application to be a Patient Patient Information All patients must fill out this section. All fields required unless otherwise noted. Patient Name Year Month Day Gender Male Female Residence Phone / Fax Required for Online Shopping with Mailing Same as Residence Where you receive correspondence, if different from residence Shipping Same as Residence Where you would like your product to arrive, if different from residence

3 The Patient and/or the Individual Responsible for the Patient Must Agree to the Following: Important, Please Read and Sign Below. The information contained in this registration application is correct and complete; The applicant is ordinarily a resident of Canada; The medical document used for this application is not being used to seek dried marihuana from another source; The original of the medical document accompanies the application; The applicant will use dried marihuana for their own medical purposes; The indications, safety and risks of dried marihuana use has not been adequately studied and the appropriate dosage is unclear. Patient acknowledges that any medical marihuana product obtained from is done so at patient s own risk and releases, Ltd. from any and all actions, claims, complaints, and demands for damages, loss or injury whatsoever arising directly or indirectly as a consequence of the use of medical marihuana products obtained from, Ltd.; The Applicant consents to the health care practitioner named in this document disclosing required personal health information to for the purposes of (i) complying with the requirements of the Marihuana for Medical Purposes Regulations (MMPR) and (ii) in order provide you with products or services in accordance with privacy policy ( The Applicant understands and agrees that a copy of this consent & registration application may be provided to the health care practitioner named herein; and The Applicant consents to receive invitations from to participate in surveys, studies or other research projects relating to the Applicant s use of s products or services, which may be conducted by or by third parties. This research may be directed to improving s products or services, or to better understanding the medicinal uses of marihuana products, generally. Participation in any such research project will be entirely voluntary and the Applicant s personal information will not be used or disclosed in any such research project without the Applicant s express consent. The Applicant may withdraw consent to receive such invitations at any time by contacting us by at privacy@tilray.ca, by mail at,, or by telephone at TILRAY1 ( ). Pursuant to Health Canada s regulations, if, after becoming a registered client, your registration is cancelled, your medical document will not be returned. of Patient / Individual Responsible

4 You re (probably) done! You only need one of the following forms if someone will be receiving medical cannabis on your behalf. Please complete the form that applies in your case and include it with your Application and Medical Document when you send in your registration envelope. Health Care Practitioner Information Use this form if a health care practitioner will be receiving your medical cannabis. There is a section they must fill out and sign as well. Caregiver Information Use this form if your caregiver will be receiving your medicine. There is a section they must fill out and sign as well. Social Services Information Use this form if you are without a residence and Social Services is consenting to receive your medicine. There is a section that your residence manager must fill out and sign as well. Having problems? A customer service representative is waiting to help you with any questions you may have. Please call us at TILRAY1 ( ). We look forward to speaking with you.

5 Health Care Practitioner Information Patients who have a Health Care Practitioner receiving product for them must fill out this section. Health Care Practitioner s Title / Name Licence / Practice Title Medical Licence Number Clinic / Business Name Business Phone / Fax If Applicable Shipping Same as Business Where you would like your product to arrive, if different from business Health Care Practitioner s Name of Health Care Practitioner consent to receive dried marihuana on behalf of Patient s Name Notice to the Health Care Practitioner: Withdrawal of consent by the Health Care Practitioner: If the health care practitioner ceases to consent and receive dried marihuana for the patient, the practitioner must send a written notice to that effect to the patient and the licensed producer.

6 Caregiver Information Patients with a caregiver must fill out this section. Caregiver Name Gender Year Male Month Female Day Contact Information address (Required for Online Shopping with ) am responsible for Name of Individual or Caregiver Responsible Patient s Name of Individual Responsible for Patient Alternate Caregiver Information Patients with an alternative caregiver must fill out this section. Caregiver Name Gender Year Male Month Female Day Contact Information address (Required for Online Shopping with ) am responsible for Name of Individual or Caregiver Responsible Patient s Name Sign and Date of Individual Responsible for Patient

7 Social Services Information Patients who are without a residence and have social services consenting to receive product for them must fill out this section. Social Services Establishment Manager s Name Name of Social Services Establishment Type of Social Services Establishment Physical Phone / Fax If Applicable Mailing Same as Physical Where you receive correspondence, if different from physical address Shipping Same as Mailing Where you would like your product to arrive, if different from mailing address attest that Manager s Name Social Services Establishment Name provides food, lodging, or other social services to Name of Patient of Manager