Step 1 of 3 33% Step 1: Fill out your Patient Intake Form We need this information for our practitioners records. This is fully secure allows them to have your file ready and guarantees your grams per day you ask for. There’s no need to be anxious about these forms, just be honest and answer to best of your ability. First Name*Your legal name is required for us to process your registration. Your legal name is required for us to process your registration.Last Name*Your full legal name is required for us to process your registration. Your full legal name is required for us to process your registration.Date of Birth* MM slash DD slash YYYY Phone Number*Please do not include a “1” in front of the number.Please do not include a “1” in front of the number.Email* Mailing Address*We need this to mail your prescription We need this to mail your prescriptionProvince*SelectAlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland & LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukonPostal code* Gender* Male Female Are you Pregnant or nursing? Yes No Grams Per Day*- Select -5g @ $12010g @ $15015g @ $17520g @ $20030g @ $30040g @ $35050g @ $40060g @ $50070g @ $60080g @ $65095g @ $725Medical Condition & SymptomsCondition(s) for which medical cannabis is being requested* Check off symptoms associated with your primary condition. Select level of symptom severity. Level 1 - not severe, Level 5 - very severePain Pain Select Severity 1 2 3 4 5 Muscle Spasms Muscle Spasms Select Severity 1 2 3 4 5 Mobility Mobility Select Severity 1 2 3 4 5 Headache Headache Select Severity 1 2 3 4 5 Seizures Seizures Select Severity 1 2 3 4 5 Involuntary Movements Involuntary Movements Select Severity 1 2 3 4 5 Anxiety Anxiety Select Severity 1 2 3 4 5 Depression Depression Select Severity 1 2 3 4 5 Concentration/Focus Concentration/Focus Select Severity 1 2 3 4 5 Sleep Disturbance Sleep Disturbance Select Severity 1 2 3 4 5 Visual Disturbance Visual Disturbance Select Severity 1 2 3 4 5 Weight Loss Weight Loss Select Severity 1 2 3 4 5 Lack of Appetite Lack of Appetite Select Severity 1 2 3 4 5 Nausea/Vomiting Nausea/Vomiting Select Severity 1 2 3 4 5 Low Energy Low Energy Select Severity 1 2 3 4 5 Diarrhea Diarrhea Select Severity 1 2 3 4 5 Constipation Constipation Select Severity 1 2 3 4 5 What is your preferred method of taking cannabis?* Inhalation/Smoke Oral/Eat Topical/Cream Concentrates Juicing All of the above What are your treatment goals?* Reduce Pain Improve Mood Improve Appetite Improve Daily Function Improve Sleep Other Other How long have you been using cannabis?*SelectLess than 1 year1-2 years3-5 years6-10 years10-20 years20-35 years35+ yearsHave you ever experienced any negative side effects while using cannabis?* No Yes If yes, please describe Step 2: Drug History and Pain Assessment You are almost done! Just a few more questions and you can book your appointment. Just answer the best you can. Brief Drug HistoryIn the past 12 months have you used any other drugs than cannabis?* No Yes If yes, please specify In the past 12 months have you used drugs other than those required for medical reasons?* No Yes If yes, please specify In the past 12 months have you abused prescription drugs?* No Yes If yes, please specify In the past 12 months have you lost your job because of drug abuse?* No Yes If yes, please specify In the past 12 months have you engaged in illegal activities in order to obtain drugs?* No Yes If yes, please specify In the past 12 months have you been arrested for possession of illegal drugs?* No Yes If yes, please specify In the past 12 months have you had medical problems as a result of your drug use (e.g. memory loss, hepatitis, convulsions, bleeding, etc.)?* No Yes If yes, please specify Brief Pain InventoryIn the past 12 months have you used cannabis for pain?* No Yes If yes, please specify What treatments or medications are you receiving for your pain?* In the past 12 months has pain interfered with any of the following activities (select all that apply)* General activity Mood Walking ability Enjoyment of life Appetite Normal work (includes both work outside the home and housework) Relations with other people Sleep Ability to concentrate Step 3: Terms and Conditions These are typical terms and conditions you would sign when you entered any new clinic. Treatment Agreement between Health Professional and PatientI* I understand that this Release and Acknowledgment contains IMPORTANT information about medical cannabis that the assessing Health Professional requires that I acknowledge and understand before he/she may issue a prescription and/or authorization for the use of medical cannabis. I further understand that the consulting Health Professional will not necessarily be assuming care for me. He/She will, however, assess and evaluate the appropriateness of my request to use medical cannabis to assist in treating the conditions and associated symptoms that I believe; from my own personal experience, medical cannabis to be helpful in treating. I accordingly confirm that the assessing Health Professional will be my medical practitioner for the sole purpose of medical cannabis authorization and/or prescriptions. I agree not to make any claim or commence any legal proceedings against the assessing Health Professional, his/her practice, my family physician or any other involved Health Professionals (such as specialists) in relation to: My use of cannabis as a medicine; and My Application, or, prescription for possessing, obtaining, and using medical cannabis. I am well aware that Health Professionals generally agree that medical cannabis; May distort perception (sight, sounds, time, touch); May impair memory and learning May impair coordination (Avoid driving for 4 hours after smoking and 8 hours after ingesting) May impair thinking and problem-solving May increase heart rate and reduce blood pressure May produces anxiety, fear, distrust, or panic I am well aware there is considerable debate and a great lack of consensus among Health Professionals about: The appropriate medical use of cannabis The appropriate dosage for medical cannabis The risks of smoking medical cannabis as compared to vaporizing or ingesting medical cannabis The risks of smoking whole plant medical cannabis as compared to extracting the medicinally active cannabinoid and medicating with same The long-term health and psychological risks associated with the use of medical cannabis The degree to which regular consumption of medical cannabis: May contribute to pulmonary infections and respiratory cancer May damage the cells in bronchial passages which protect the body against inhaled microorganisms and decrease the ability of the immune cells in the lungs to fight off fungi, bacteria, and tumour cells. For patients with already weakened immune systems, this means an increase in the possibility of dangerous pulmonary infections, including pneumonia May weaken various natural immune mechanisms, including macrophages and T-cells May correlate in some cases with mental illness, such as bipolar disorder and schizophrenia I am further well aware that the above listed medical concerns are further compounded by the lack of consistency and uniformity in available medical cannabis products. With conventional drug products, I generally consume a medication of a precisely known molecular quantity. I recognize that raw plant Medical Cannabis does not work this way. I appreciate that I will get varying compositions of different cannabinoids and varying proportions of different cannabinoids from strain of plant to strain of plant and even, to a lesser degree, from plant to plant of the same strain. I further appreciate that there is significant uncertainty regarding the consistency of the medical cannabis drug product I may medicate with which further complicates and compounds the practical issue of medicating with an inconsistent drug product like medical cannabis. I am further aware that ingesting a high dose of medical cannabis can cause nausea and disorientation. I am seeking medical cannabis treatment and I confirm I have consulted with a Health Professional regarding alternative and conventional treatment options for my condition. Despite all these medical concerns, debates and practical issues I honestly believe that for the treatment of my condition(s) and symptom(s) the benefits of medicating with medical cannabis outweigh the risks. I agree to receive a “medical document” (i.e. prescription) for medical marijuana only from one Health Professional. I agree to purchase my marijuana only from a Licensed Producer. I am aware that possession of marijuana from other sources is illegal. I agree to safely store my marijuana so that no other person can access it either deliberately or accidentally. I will ensure that no child or young person will be exposed to my medical marijuana either directly or indirectly. I will contact Poison Control immediately if any child gains access to my supply of medical marijuana. I am aware that taking marijuana with other substances, especially sedating substances, may cause harm and possibly even death. I will not use illegal drugs (e.g. cocaine, heroin) or controlled substances (e.g. narcotics, stimulants, anxiety pills) that were not prescribed for me. I will inform the Health Professional of all controlled substances that are prescribed to me by my regular Health Professional(s). I will inform my primary care Health Professional that I am being prescribed medical marijuana. I agree to have a medical assessment performed by my regular Health Professional at least every 12 months. I am aware that marijuana use is not advisable during pregnancy and breastfeeding. I agree to inform my Health Professional if I am pregnant. If I become pregnant while being treated with medical marijuana, I will immediately stop using it until I have consulted with a Health Professional. This is my decision, and I also do not support any claims made by my family, friends or other interested parties against said clinic and Health Professionals. I hereby release Cann Grow Consulting, the assessing Health Professional, his/her clinic, my family Health Professional, and any other involved Health Professionals from any and all actions, claims, causes of actions, complaints (even by family and friends) and demands for damages, loss, or injury whatsoever arising directly or indirectly as a consequence to my use of medical cannabis and my Application to posses medical cannabis. This release from liability is to be binding on heirs, executors and assigns. I also consent to the disclosure, sharing and use of my personal information and medical data by the assessing Health Professional, Health Canada, Cann Grow Consulting and my Licensed Producer. The information may be used to contact, assess and register the patient and for analysis and research to better help our members. I understand and acknowledge that while the assessing Health Professional may execute a declaration that I stand to potentially benefit from medical cannabis, the assessing Health Professional will not serve as my primary care Health Professional. As such I agree, to seek regular medical care from my primary care Health Professional and that the assessing Health Professional will only deal with assessing his/her support for my medical cannabis use. I also consent to the assessing Health Professional notifying any specialists that have seen of my decision to use medical cannabis, and I accept any consequences of such notification. I agree to notify my primary care Health Professional myself about my intent to use cannabis medicinally as cannabis can interact with other medications. If licensed, I agree not to resell or give away any of my medication. I agree to check with local bylaws in my area. I also agree that any legal actions will take place in Ontario and be governed by the laws of Ontario, Canada. I agree to the terms of cancellation and rescheduling. Appointments cancelled prior to 48 hours before scheduled time will receive a full refund Appointment cancelled between 48 hours and 24 hours in advance will receive a partial refund of total cost minus a $100 administration fee Appointments cancelled less than 24 hours will receive no refund Missed appointment will receive no refund If an appointment is missed, patient may call back the number on the same day or next day. If we do not hear from the patient for more than 24 hours after missed appointment they fall into the no refund category. Patient Signature*Patient Name* Date Signed* MM slash DD slash YYYY EmailThis field is for validation purposes and should be left unchanged.