APPLICATION CHECKLIST
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1 APPLICATION CHECKLIST 1 Print the complete application package Read, initial and sign the Code of Conduct Read and fill out the Application Form Make an appointment with your Healthcare Practitioner. We accept completed forms from Doctors, Doctors of Traditional Chinese Medicine and Naturopaths. Healthcare Practitioner: Address: Date: Time: Have your Healthcare Practitioner fill out the Healthcare Practitioner s Statement. Ask that they fax the completed form directly from their office to Nature s Botanicals at FOR LOCAL PATIENTS Once we receive your Healthcare Practitioner s Statement, come to Nature s Botanicals with your completed Code of Conduct and Application Form. You will then be issued a client membership card. FOR MAIL ORDER PATIENTS Mail, fax or your completed forms to Nature s Botanicals. If ing the forms you must provide a signature on both the Code of Conduct and Application Form. Nature s Botanicals will contact you once the application package has been received and processed.
2 DESCRIPTION OF FORMS 2 1 Application Checklist Use this checklist to ensure that your application package is complete 2 Description of Forms A list of all the forms included in the application package 3 Code of Conduct This form must be read, initialled and signed by every member of Nature s Botanicals 4 Application Form This form must be completed and signed by every member of Nature s Botanicals 5 Healthcare Practitioner s Statement A provincially licensed healthcare practitioner completes and faxes this form to Nature s Botanicals 6 Medical Information Release Authorization This form authorizes your healthcare practitioner to send copies of your Healthcare Practitioner s Statement and confirmation of diagnosis to Nature s Botanicals 7 Information for Healthcare Practitioners Use this form letter to provide your healthcare practitioner with additional information regarding the use of medical cannabis
3 CODE OF CONDUCT 3 As a result of the inherent risks in delivering medicinal cannabis in the current legal/political environment, Nature s Botanicals reserves the right to refuse service to any client for any reason. Violation of this Code of Conduct may result in permanent refusal of service at the sole discretion of Nature s Botanicals. Reselling any products obtained from Nature s Botanicals will result in immediate and permanent refusal of service. Read and initial each line to verify understanding of the terms. LEGAL The production, sale and possession of cannabis and cannabis products is illegal in Canada. Know your rights and take precautions in order to avoid possible legal charges. Keep a copy of your healthcare practitioner s statement with you at all times when possessing cannabis in public. RESPONSIBILITY Cannabis and cannabis products, like any medicine, must be stored and used responsibly. IMPAIRMENT Cannabis may cause temporary impairment of motor functions, coordination and cognitive function such as short-term memory. Edible cannabis products often require additional time to take effect and can have more powerful effects than smoked or vaporized cannabis. Edibles should be used with caution until an appropriate dosage is established. SUBSTANCE INTERACTIONS Cannabis may have negative interactions with certain pharmaceutical drugs and other substances, including alcohol. Consult a healthcare practitioner before using cannabis or cannabis products with any other substance. CARDIAC Cannabis causes temporary increases in heart rate coupled with decreased blood pressure. This may result in temporary lightheadness or dizziness. If you have cardiac or blood pressure issues, or are taking medications for cardiac-related issues, consult with your healthcare practitioner before using cannabis or cannabis products. NO REPRESENTATIONS OR WARRANTIES Nature s Botanicals makes no guarantees, representations or warranties, express or implied, about the effectiveness of cannabis for your particular medical condition or symptom. RELEASE By signing this document, you fully and completely release Nature s Botanicals and its employees from any claim, demand, suit or obligation of any kind. I,, (print name) have read and understand this Code of Conduct and agree to abide by its terms and conditions. Signature: Date:
4 APPLICATION FORM 4 For office use only Account # Verified by Date Practitioner Provincial # Name Date of Birth / / (DDMMYY) Male Female Address City Province Postal Code Home Phone ( ) Cell Phone ( ) Address Applicant Declaration and Signature I have discussed the potential benefits and risks of using cannabis with the healthcare practitioner in support of my application, and I consent to using cannabis only for the treatment of the symptoms stated in the medical declaration. I am aware and accept that the benefits and risks associated with the use of cannabis are not fully understood and that the use of cannabis may involve unidentified risks. I am aware that a notice of compliance has not been issued under the Food and Drug regulations concerning the safety and effectiveness of cannabis and I understand the significance of this fact. I confirm that the information on this form is correct and complete. Applicant Signature Print Name Date (DD/MM/YYYY)
5 5 HEALTHCARE PRACTITIONER S STATEMENT This form must be completed by a MD, DTCM or ND Fax to Nature s Botanicals Toll Free I recommend cannabis to help my patient with his/her symptoms. This patient has reported that his/her symptoms are aided by cannabis and therefore, on the basis of my knowledge, he/she should have access to medicinal cannabis and cannabis products. The proposed daily amount of cannabis is less than or equal to grams (please use letters to indicate amount). Patient s Name DOB / / (DDMMYY) Practitioner s Name License # Business Address City Province Postal Code Phone ( ) Method of administration indicated: inhalation oral topical I am a healthcare practitioner with an area of expertise that is relevant to the applicant s medical condition OR I am not in an area of expertise but do declare that: The applicant s case has been assessed by a specialist with an area of expertise that is relevant to the applicant s medical condition. The specialist concurs that conventional treatments for the applicant s symptoms are ineffective or medically inappropriate and that he/she is aware that cannabis is being considered as an alternative treatment for the applicant. Healthcare Practitioner s Signature Date (DD/MM/YYYY)
6 6 MEDICAL INFORMATION RELEASE AUTHORIZATION This form has been designed to ensure that confidentiality is a respected right, and to make provisions for the exchange of relevant information between service workers. I, hereby request that my: Healthcare Practitioner s Statement and/or prescription Confirmation of membership Confirmation of diagnosis Other be released from and forwarded to Nature s Botanicals. This consent is valid for one time only; any additional releases of information will require my consent. Nature s Botanicals is prohibited from sharing my information without my written consent. Patient s Name Signature Date / / (DDMMYY)
7 7 INFORMATION FOR THE HEALTHCARE PRACTITIONER Dear Healthcare Practitioner, Your patient is requesting membership with Nature s Botanicals. We at Nature s Botanicals have created safe and supportive access to clean, high quality, affordable cannabis for those in medical need. In order to maintain the level of legitimacy expected from our company, Nature s Botanicals requires a confirmation of diagnosis and/or recommendation from a Medical Doctor, Doctor of Traditional Chinese Medicine or Naturopath as a requirement for membership. Many healthcare practitioners recognize the effectiveness of cannabis in their patients treatment and are referring their patients to us. As part of our orientation to Nature s Botanicals, members learn about the safe and effective use of cannabis and the variety of alternative delivery methods available to them, such as dried cannabis, edibles and tinctures. We have attached legal and medical information for you to read. For more information on the use of cannabis for specific symptoms and conditions, please feel free to contact us or consult the website In the Canadian Medical Association Journal (issue 161(8), pg October 19, 1999), Dr. Morris Van Andel, then Deputy Registrar of the College of Physicians and Surgeons of BC, advises doctors to write a confirmation of a patient s medical condition rather than an illegal prescription. I would say I am writing to confirm that Mr. Smith is HIV positive and that he has indicated that his chronic pain is helped by marijuana and therefore should such a substance be available to him, that on the basis of my knowledge of him, he should be eligible for that type of help. Please fill in the attached Healthcare Practitioner s Statement and fax it to Nature s Botanicals. If you only feel comfortable confirming your patient s diagnosis, you may do so on the form or provide a confirmation of diagnosis with the date, your name and signature on your letterhead or prescription pad. Respectfully, Nature s Botanicals
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