Welcome, Clients of Trichome Consulting Services

WELCOME, CLIENTS OF MEDICAL CANNABIS PRIME

ALL APPOINTMENTS ARE IN EASTERN STANDARD TIME (EST)

WHAT TYPE OF APPLICATION ARE YOU MAKING?*

LICENCE TO OBTAIN MEDICAL CANNABIS FROM A LICENSED PRODUCER
LICENCE TO GROW FOR MEDICAL PURPOSES

RENEWAL*

Do you have a non-expired licence that you wish to renew?

Yes, I have an active licence and want to renew.
No, I need a new licence.

Are there any changes to your renewal?*

Yes
No

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Appointment*

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Provider*

Desired Appointment Date*

Select a time for your appointment. Eastern Standard Time (EST)

September 2023

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How much cannabis do you consume per day or do you want to consume?*

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

Name on ID*

First Last

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FIRST NAME ON ID*

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LAST NAME ON ID*

DATE OF BIRTH*

For Veterans

PROVINCIAL HEALTH CARD NUMBER*

ISSUING PROVINCE*

GENDER*

e-mail*

STREET NUMBER AND NAME*

APARTMENT

PROVINCE*

CITY*

POSTAL CODE*

Phone*

• Please include a photo ID and any medical documents or list of medications that may be required.*

Drop files here or

Accepted file types: pdf, doc, docx, jpg, jpeg, png, gif, heic, Max. file size: 20 MB.

REFERAL CODE*

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

• 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*

Do you have family history of:*

Alcohol Abuse
Illegal Drug Abuse
Prescription Drug Abuse
None

Do you have personal history of:*

Alcohol Abuse
Illegal Drug Abuse
Prescription Drug Abuse
None

Have you ever been diagnosed with, or experienced:*

Preadolescent Sexual Abuse
Attention Deficit Disorder
Obsessive Compulsive Disorder
Bipolar Disease
Depression
None

Have you ever been diagnosed with Schizophrenia?*

Yes
No

Are you currently incarcerated, or under the care of a correctional service?*

Yes
No

How long have you been using Cannabis?*

What is your preferred method(s) of consuming Cannabis?*

Inhalation / Smoking
Orally / Eating
Topical / Creams
Other

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.

Accept All

Accept All

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 attack 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 Medical Cannabis Prime or the prescribing specialists/physicians.

I agree

9*

I hereby release Medical Cannabis Prime, 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

9*

I hereby release Medical Cannabis Prime, Trichome Consulting Services Inc., 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 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, canceling my application.

I agree

12

Accept Marketing Emails From Partners/newsletters And Promotions

13*

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

Application

ALL APPOINTMENTS ARE IN EASTERN STANDARD TIME (EST)

September 2023

Legal