Field with Asterisk ( * ) is Required.


Please check all medical conditions for which you wish to use medical cannabis :

Please explain all conventional therapies you have attempted to manage the medical condition(s) in which you are seeking to use medical cannabis, and why they were unsuccessful :

List the name, last date seen, and type of health care provider (doctor, chiropractor, therapist, counselor, specialist, etc.) that you have consulted for your medical condition(s) :

Name Date Last Seen Type of Health Care Provider


Are you currently experiencing any of the following? Check all that apply :

Do you have a history of substance abuse? Check all that apply :

Please list the prescriptions and/or over-the-counter supplements that you are currently taking :

Previous medications tried? Check all that apply :


Please check all that apply :


Please check all that apply :


Please check all that apply :


How often do you use cannabis?

How have you used cannabis? Check all that apply.

Do you use your vaporizer recreationally or for medical reasons?

Which strains have you used?

How much marijuana do you currently use per day, in grams?

Have you had any serious reactions to cannabis?



Over the past 2 weeks, have you been bothered by the following? Check your answer below.

0 - not at all
1 - several days
2 - more than half of the days
3 - nearly every day

If you identified issues above, how difficult have they made it for you to do your work, take care of things at home, or get along with other people?


Over the past 2 weeks, have you been bothered by the following? Check your answer below.

0 - not at all
1 - several days
2 - more than half of the days
3 - nearly every day

If you identified issues above, how difficult have they made it for you to do your work, take care of things at home, or get along with other people?


1. Throughout our lives, most of us have had pain from time to time (such as minor headaches, sprains, and toothaches). Have you had pain other than these everyday kinds of pain today?


2. On the diagram, check the number of areas where you feel pain.

3. Please rate your pain by choosing the number that best describes your pain at its worst in the last 24 hours. (1 - No Pain ; 10 - Extreme Pain)


4. Please choose the number that best describes your pain at its least in the last 24 hours. (1 - No Pain ; 10 - Extreme Pain)


5. Please rate your pain by choosing the number that best describes your pain on the average. (1 - No Pain ; 10 - Extreme Pain)


6. Please rate your pain by marking the box beside the number that tells how much pain you have right now. (1 - No Pain ; 10 - Extreme Pain)


7. What treatments or medications are you receiving for your pain?

8. In the last 24 hours, how much relief have pain treatments or medications provided? Please choose corresponding number below. (1 - No Relief ; 10 - Fully Relieved)


9. Choose the number that describes how, during the past 24 hours, pain has interfered with your : (1 - No Interference ; 10 - Completely Interferes)

General Activity




Walking Ability


Normal Work (includes both work outside the home and housework)


Relations with other people




Enjoyment of Life



1. Is there a family history of substance abuse? Check all that Apply.

2. Do you have a history of preadolescent sexual abuse?

3. Is there a family history of psychological disease? Check all that Apply.

* Where did you hear about us?



     In the event that the company proceeds with the reorganization, sale, lease, merger or amalgamation or any other type of disposal or financing of the company or a portion of the company or of any of the business or assets of the company, the company shall comply with the requirements set out in Ontario's Freedom of Information and Protection of Privacy Act.

     The company may collect, use, share and access different types of information or data about the company’s clients and/or patients in such ways that do not identify such individuals directly (e.g. by name) or indirectly (e.g. by date of birth) and for statistical purposes only. Such information may include personal characteristics or other information about which an individual has a reasonable expectation of privacy (e.g., age, ethnicity, health history, life experience, social status). The company does not release any information that could identify individuals without their consent. The company covenants that all personal information (within the meaning attributed thereto in applicable legislation in Ontario) of or with respect to the patients shall only be used, disclosed or dealt with in strict compliance with applicable privacy legislation.

Who has Access to Information Collected?

     We strictly control access to your personal information to our employees who need this information in order to serve you or to employees who analyze our performance in order to measure and improve our services. Employees are kept up-to- date with regard to the privacy and security practices of and Green Card Canada.

     We reserve the right to co-operate with local, provincial and national officials in any investigation requiring either personal information including any personal information provided online or reports about lawful and unlawful user activities on the Website.

     If you ask us, we will remove any information about you from our files, unless some legitimate purpose makes its reasonable for us to retain it for some additional time. We will also review our files from time to time with a view to identifying and deleting stale information.


By signing this document, you acknowledge that you have been informed of and undestand the following.

1. The medical practitioner, the clinic staff, and/or clinic representatives are neither providing nor dispensing medical marijuana.

2. Prior to your appointment, you are required to submit a copy of your most recent government issued photo ID.

3. The medical practitioner is evaluating you for the use of medical cannabis and will make their recommendation based in part, on the medical information you have provided. It is your responsibility to ensure that there is no misrepresentation of your medical information submitted in order for you to obtain a recommendation to use cannabis for your medical condition.

4. You agree to only use medical cannabis for the treatment of your medical condition as agreed upon by the physician and not for recreational or non-medical purposes.

5. The medical practitioner is addressing specific aspects of your medical care and, unless otherwise stated, is in no way establishing herself as your primary care physician.

6. Should the medical practitioner approve you for the use of medical cannabis, it is your responsibility to ensure that a renewal appointment is made one month prior to your expiry date. During your renewal appointment the physician will re-evaluate the possible continuance of cannabis.

7. You understand that it is your responsibility to stay informed regarding provincial and federal laws regarding the possession, use, sale/purchase and/or distribution of medical marijuana.

8. Marijuana is not recommended if you are pregnant or breastfeeding. If you think you may be pregnant or are thinking about becoming pregnant, speak with your Practitioner.

9. Health Canada, the medical practitioner and Green Card Canada clinic staff advise you that using cannabis is prohibited while driving or performing hazardous tasks such as operating heavy machinery. The same applies to safety-sensitive occupations such as health professionals and the supervision of children. Depending on dosage and administration, impairment can last over 24 hours following last usage.

10. The potential side effects from the use of marijuana include, but are not limited to the following; dizziness, anxiety, confusion, sedation, low blood pressure, impairment of short-term memory, euphoria, difficulty in completing complex tasks, suppression of the body’s immune system, inability to concentrate, impaired motor skills, paranoia, psychotic symptoms, general apathy, depression and/or restlessness.

11. Marijuana may exacerbate schizophrenia in persons predisposed to the disorder.

12. Marijuana use may also cause excessive talking and eating, alter your perception of time and space and impair your judgment.

13. You understand that using marijuana while under the influence of alcohol is not recommended. Additional side effects may become present when using both alcohol and marijuana.

14. Smoking marijuana may cause respiratory problems and harm, including; bronchitis, emphysema and laryngitis. In the opinion of many researchers, marijuana smoke contains known carcinogens (chemicals that cause cancer) and smoking marijuana may increase the risk of respiratory diseases and cancers in the lung, mouth and tongue. In addition, marijuana smoke contains harmful chemicals known as tars. If you begin to experience respiratory problems when using marijuana, you agree to stop using it and report your symptoms to a physician.

15. The medical practitioner and/or the Green Card Canada clinic staff will inform you of alternatives to smoking marijuana.

16. The risk, benefits and drug interactions of marijuana are not fully understood. If you are taking medication or undergoing treatment for any medical condition, you understand that you should consult with your primary care physician(s) before using marijuana and that you should not discontinue any medication or treatment previously prescribed unless advised to do so by your primary care physician.

17. Individuals may develop a tolerance to and/or dependence on marijuana. If you develop signs of withdrawal, which can include; feelings of depression, sadness, irritability, insomnia, restlessness, agitation, loss of appetite, trouble concentrating, sleep disturbances, and unusual tiredness, contact Green Card Canada staff.

18. Symptoms of marijuana overdose include but are not limited to; nausea, vomiting, hacking cough, disturbance in heart rhythm, numbness in hands, feet, arms or legs, anxiety attacks and incapacitation. If you experience these symptoms, you agree to contact your primary care physician, call 911 or go to the nearest emergency room.

19. If Green Card Canada subsequently learns that the information you have furnished is false or misleading, the recommendation by the physician for marijuana may be revoked. You agree to promptly meet the Green Card Canada staff and/or provide additional information in the event of any inaccuracies or misstatements in the information you have provided.

20. Recommendations made by the Green Card Canada about Licensed Producers, strains and methods of intake are recommendations ONLY. Green Card Canada reserves the right to discuss your information with your licensed producer and you agree with your licensed producer sharing information about your application and recommendation with Green Card Canada.

21. If you do not understand any of the above, you agree to contact Green Card Canada for clarification.

22. I authorize any Green Card Canada medical practitioner to make direct contact with a current, treating primary care physician to determine whether excessive use of marijuana has harmed myself, the patient.

23. I understand that the information I have been asked to provide to Green Card Canada and/or the medical practitioner is for the diagnosis and treatment of the medical condition(s) for which I want to access medical marijuana. I understand that if I have not accurately and completely disclosed the requested information, it may adversely impact the physician’s ability to diagnosis my condition and recommend appropriate medical marijuana treatment.

By submitting this form I have read, understood and consent to the above information to comply, be true and correct.

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