Pre-Rolls

Welcome, Clients of Gimmy Cannabis

How much cannabis do you consume per day or do you want to consume?(Required)

DATE OF BIRTH(Required)

PROVINCIAL HEALTH CARD NUMBER(Required)

ISSUING PROVINCE(Required)

GENDER(Required)

Email

Phone

Please include a photo ID and any medical documents or list of medications that may be required.(Required)

Drop files here or

Max. file size: 64 MB.

Describe your medical conditions that lead you to apply for access to medical cannabis (i.e. chronic back pain, ...)(Required)

How long have you suffered from this or these condition (s)?

DESCRIBE ANY THERAPY OR TREATMENT YOU CURRENTLY DO FOR YOUR CONDITION(S)

WEIGHT

HEIGHT

CURRENT DOCTOR

If you don't have one, type "none"

PLEASE LIST ANY AND ALL MEDICATIONS YOU CURRENTLY TAKE

PLEASE LIST ANY KNOWN ALLERGIES

How long have you been using Cannabis?

Legal

Release, 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.

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