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MEDICAL DOCUMENT

To be completed by a Health Care Practitioner.

PATIENT INFORMATION

Information must match information on patient registration

Patient Name*

First Name Last Name

Date of Birth *

Date of Birth*

Year

Month

Day

Caregiver Required? *

Caregiver Required?*

*If yes, please complete in full the Caregiver form attached to this medical document.

Period of Use - Month(s)*

Please enter a value between 1 and 12.

Note: Duration Cannot Exceed One Year

Dried Only
Extract Only

If neither option is selected, the patient will be able to order any combination of extracts or dried cannabis products.

Telephone*

Fax

Email*

Daily Prescription*

Grams/Day

Primary Condition*

HEALTH CARE PRACTITIONER INFORMATION

Please type clearly in full (no abbreviations).

Title / Name*

Title Given Name Surname

Profession*

Business / Clinic Name*

Business Address *

Business Address*

Address City Province Postal Code

Consultation Address *

Consultation Address

Address City Province Postal Code

Address of Consultation Location with Patient (If Different Than Above)

Telephone (Required)*

Fax (If Applicable)

Email (If Applicable)*

Licence Number*

Licence number issued by Provincial College Note: Do not enter billing number (e.g. MSP no.)

Province of Practice*

Province in which Practitioner is Authorized to Practice

Signature *

Signature*

By signing, the Practitioner attests that the information in this document is correct and complete.

Date*

Year

Month

Day

Practitioner Initials*

By initialling, Practitioner acknowledges that the Medical Document faxed to Tidal constitutes the original Medical Document and that he/she has retained a copy of the Medical Document for his/her records. Practitioner also attests that the Medical Document will not be faxed or provided to any party other than Tldal.

MEDICAL DOCUMENT

PATIENT INFORMATION

HEALTH CARE PRACTITIONER INFORMATION

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