Online Application Step 1 of 8 - Identity 0% This field is hidden when viewing the formSourceIDApplication TypeWhich type of application are you making?* Licence to Obtain Medical Cannabis from a Licenced Producer Licence to Grow Cannabis for Medical Purposes First Time?*Is this your first time applying for a Medical Cannabis licence? Yes No Proof of Existing LicenceUpload a copy of your current licence, if available. Drop files here or Select files Accepted file types: jpg, gif, png, pdf, jpeg, Max. file size: 512 MB, Max. files: 3. Book a ConsultationAll new applicants require a consultation with a member of our medical team. To expedite the process, we strongly suggest you take a moment right now to book an appointment. >> Please click here for availability << and select a time most convenient for you. All applications require a consultation with a member of our medical team. To expedite the process, we strongly suggest you take a moment right now to book an appointment. Please click here for availability and select a time most convenient for you. Completed Booking?* Yes, I have booked a consultation using the link above. Please input today's date in the consultation date box below:Date of Consultation*Please confirm the date you selected for your consultation. ** DOUBLE CHECK THIS IS THE CORRECT CONSULTATION DATE ** Month Day Year Section 1a: Your HistoryIn this section, we ask about your past use of Cannabis and/or Medical Cannabis. Only Medical Doctors and their staff will see this information to assist in obtaining your prescription.Have you ever used Cannabis before?* Yes No This field is hidden when viewing the formauthqty1Have you ever received a prescription for Medical Cannabis before? Yes No What amount were you prescribed, in grams per day?Did you find this amount sufficient for your needs? Yes No This field is hidden when viewing the formauthqty3This field is hidden when viewing the formauthqty4Section 1b: Your HistoryIn this section, we ask about your past use of Cannabis and/or Medical Cannabis. Only Medical Doctors and their staff will see this information to assist in obtaining your prescription.Previous AuthorizationYou've indicated you are renewing a licence. Please enter the number of grams per day you are currently authorized forApplication QuantityPlease enter the number of grams per day you are applying to grow.This field is hidden when viewing the formSection BreakThis field is hidden when viewing the formqty authorized Section 2: Your SourceIn this section, we ask about your preferred source of medical product.You have indicated that you've never used Cannabis before. This means you may not know where you'd like to purchase from - that's OK! Simply select "other/I don't know" and we'll reach out to you with suggestions.Provider*As part of our service, we send all required medical documents directly to the Licenced Producer of your choice. If you are unsure, please select "other". Note: You may choose more than one. ABcann (Beacon)Acreage PharmsAphriaAuroraBlissCoBroken CoastCannTrustCanniMedCanna FarmsHydropothecaryMedReleafSpectrum CannabisSolace HealthOther / I don't knowPureCropTilrayWhistler Medical MarijuanaWeedMDThis field is hidden when viewing the formDeliverbyemailProvider Consultation*Would you like the provider(s) you have chosen to contact you before they open your account? Yes No Section 3: IdentityThis section collects personal information required by Health Canada. It is stored securely using military-grade SSL encryption and protected from tampering by a technology called Blockchain.First name, as it appears on your government-issued ID*Last name, as it appears on your government-issued ID*Middle name(s)Date of Birth* Month Day Year Health Card Number*Gender* Male Female Other/Prefer not to say Your complete address, including postal code*Your Email Address* Phone Number*A phone number where you can be reached by our team of Doctors and SpecialistsGovernment-issued ID*Please upload a photo of the front and back of any Government-issued ID, matching the name you entered above. Drop files here or Select files Accepted file types: jpg, gif, png, pdf, jpeg, Max. file size: 512 MB, Max. files: 3. Referral CodeIf you have been given a referral code, please enter it here.Agree* I agree this section has been completed truthfully. Section 4: Medical ProfileDescribe your primary medical conditions (ie., chronic back pain)*For how long?Your height*Your weight*Your current Doctor or Specialists namePlease list any and all medications you currently takePlease list any known allergiesAgree* I agree this section has been completed truthfully. Section 5: Risk AssessmentCheck only the boxes that are applicable to you.Do you have family history of: Alcohol Abuse Illegal Drug Abuse Prescription Drug Abuse Do you have personal history of: Alcohol Abuse Illegal Drug Abuse Prescription Drug Abuse Have you ever been diagnosed with, or experienced: Preadolescent Sexual Abuse Attention Deficit Disorder Obsessive Compulsive Disorder Bipolar Disease Depression Have you ever been diagnosed with Schizophrenia?* Yes No Are you currently incarcerated, or under the care of a correctional service?* Yes No Agree* I agree this section has been completed truthfully. Section 6: Cannabis as MedicineYour history indicates that you have never used Cannabis before. Can you describe other ways you have attempted to manage your condition?Why is Cannabis an effective/appropriate medical treatment for you?*How long have you been using Cannabis?*What is your preferred method(s) of consuming Cannabis?* Inhalation / Smoking Orally / Eating Topical / Creams Other Agree* I agree this section has been completed truthfully. Section 7: LegalRelease, Acknowledgement & Indemnity Agreement for Patients seeking a Medical Cannabis document By typing your name below or clicking "I agree", you legally indicate your understanding and acceptance of the following:1*I, (type your name), understand that this Release and Acknowledgement contains valuable information about possessing/cultivating and consuming prescribed medical cannabis, that the assessing specialist/physician requires to issue a medical document for the access to cannabis for medical purposes regulations (ACMPR). I also understand that the consulting specialist/physician will not be assuming primary care for me, and will only be recognized as my ACMPR prescribing practitioner. I understand and agree to continue regularly seeing my primary care physician for my medical condition(s) on a regular basis and agree to inform them of my medical cannabis use.2*I confirm that the assessing specialist/physician will be the only practitioner providing a medical document under the ACMPR for the purpose of possessing/cultivating and consuming medical cannabis. I agree 3*I agree to make no claims or commence any legal action against the assessing physician/specialist/representative, my family physician, or any other involved person(s) in regards to both my consumption of medical cannabis and my application or medical document(s) for possessing, obtaining, cultivating and consuming medical cannabis. I agree 4*I am fully aware that specialists & physicians generally agree that medical cannabis may affect sight, sounds, and the sensation of touch. It may impair thinking, problem solving, coordination, memory or learning. Medical cannabis may increase heart heart and reduce blood pressure, and could induce fear, anxiety, distrust or panic. I agree 5*I am fully aware that medical conditions such as schizophrenia, atrial fibrillation, heart attack/stroke or use of blood thinners may result in the denial of my application to possess and consume medical cannabis. I am also aware that if pregnant or planning to become pregnant, medical cannabis should not be used during breastfeeding. I agree 6*I am aware of the considerable debate and lack of consensus among physicians/specialists regarding the following topics: The appropriate dose and medical use of cannabis. The risks of burning medical cannabis compared to vaporizing or ingesting. The risks of burning extracted cannabinoids such as oil or hashish. The long term risk psychological and health risks associated with medical cannabis. The risks of pulmonary infections and respiratory cancer. The risks of triggering mental illness, such as bipolar disease or schizophrenia. The risk of nausea and disorientation. I agree 7*I consent to the disclosure, sharing and use of my personal information and my personal health information by the assessing specialist/physician, and my licensed producer. The information may be used to contact and register the patient, and may also be used anonymously for analytical and research purposes. I agree 8*I truthfully believe that treating my personal medical condition(s) with medical cannabis potentially or has had a positive effect, and the benefits outweigh the potential risks associated. It is my personal decision to possess and consume medical cannabis and I do not support any claims made by family, friends, or other individuals against The FastCann or the prescribing specialists/physicians. I agree 9*I hereby release FastCann, our partners, the prescribing specialist/physician, other employees or team members, from any and all claims, actions, causes of actions, complaints (including friends and family), and demands for damages, losses, or injury arising directly or indirectly from my use of medical cannabis and/or my application to possess, cultivate, or consume medical cannabis. I agree 10*If my prescription is approved, I agree not to resell or give away any of my medication. I have read and understood the limitations and regulations set forth by Health Canada. I agree to check with local bylaws in my area. I also agree that any legal actions will take place in the province of British Columbia, and be governed by the laws of B.C., Canada. I agree 11*This release from liability is to be binding on heirs, executors, agents and attorneys. I acknowledge that I have the right to disagree to these terms, cancelling my application. I agree 12*I have carefully read and understood the questions and conditions on this form. I have double checked for errors, and my answers have been truthful. I agree How did you hear about our company?Security Verification Δ Row triangle Shape Decorative svg added to top Copyright (c) FastCann Ltd.
