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Medical Document Intake Form

Kindly make sure all details are correct. You will be emailed a copy of your answers as well. Kindly wait for the confirmation email.

Medical Form
RENEWAL: Do you have a non-expired license that you wish to renew?
Name on ID
Name on ID
if you don’t have one, type “none”
Do you have family history of:
Do you have personal history of:
Have you ever been diagnosed with, or experienced:
Have you ever been diagnosed with Schizophrenia?
Are you currently incarcerated, or under the care of a correctional service?
What is your preferred method(s) of consuming Cannabis?
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:
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 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 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 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 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 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 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 hereby release 6ixotics Medical, 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.
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.
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 have carefully read and understood the questions and conditions on this form. I have double checked for errors, and my answers have been truthful.