www.delta9.ca | Medical Document

PO Box 68096 Osborne Village Winnipeg, MB R3L 2V9

info@delta.ca Fax: 1-204-975-9396

Phone: 1-855-245-1259

How to Complete the Medical Document

The Medical Document MUST be completed by a licensed Health Care Practitioner, and can be faxed to Delta 9 Bio-Tech from the practitioner’s office. Follow these steps to complete the Medical Document, as per the ACMPR regulations:

Section 1: Health Care Practitioner’s Information

Step 1: Clearly print your title, first and last name. Do not write an initial as your first name, we require a full name

Step 2: Provide your CPS license number (Not your billing number).

Step 3: Print your profession (Field of Practice/Specialty).

Step 4: Clearly print your business street address, city, province and postal code. A stamp/sticker is acceptable, providing

it has all the requested information.

Step 5: Provide your business phone number.

Step 6: Provide your fax number and/or an email address (if applicable).

Step 7: Provide the province that you’re authorized to practice within.

Step 8: Print or stamp/sticker the address of where the consultation with the patient took place, if different than the business address listed above.

Section 2: Patient Information

Step 1: Clearly print the patient’s first and last name (The name on the application form and medical document must be the same).

Step 2: Print the patient’s date of birth.

Step 3: Print the number of grams you would like your patient to use on a daily basis. This must be an exact number and not a range (Example: 3 grams, NOT 1-3 grams).

Step 4: Print the duration the medical document is to be valid, in either days, weeks, or months. Note: The max duration of a medical document is 1 year. For each medical document written, new or renewal, the patient’s application form will be required.

Step 5: The medical diagnosis is mandatory if prescribing for a veteran, otherwise it is optional.

Section 3: Product shipped to Health Care Practitioner

Step 1: Should you wish to receive dried marihuana on behalf of the patient to distribute as you deem appropriate, check mark the box indicating the preferred shipping address. The shipping address on the patient’s application form will need to match your address. Note: A patient may NOT possess more the 150 grams, or 30 times the prescribed daily amount, whichever is smaller.

Section 4: Consents

Step 1: Please sign and date the medical document. Note: The date signed constitutes the start date of the medical document (the period of use begins).

Step 2: Delta 9 will verify the medical document as per ACMPR regulations, when a practitioner is unknown to us. Check mark your preferred method.

Step 3: Submit the document: Option 1) You may fax this medical document from the business fax number you listed.

Option 2) Make a copy for your records and send the original by mail.

Instructions

www.delta9.ca | Medical Document

P.O. Box 68096 Osborne Village Winnipeg, MB R3L 2V9

info@delta9.ca Fax: 1-204-975-9396

Phone: 1-855-245-1259 Medical Document

The Medical Document must be completed by a Health Care Practitioner and submitted to Delta 9 by secure fax from the doctor’s office only or mail the origi-nal document . The patient must complete our Application Form and submit to our office by mail, email or fax. These documents are required for registration.

Health Care Practitioner’s First & Last Name: _____________________________________________________

License Number (CPS#): _____________________________________________________

Profession (Field of Practice/Specialty): _____________________________________________________

Health Care Practitioner’s Business Street Address: _____________________________________________________

City, Province and Postal Code: _____________________________________________________

Phone Number: _____________________________________________________

Fax Number (If applicable): _____________________________________________________

Email Address (If applicable): _____________________________________________________

Province Authorized to Practice In: _____________________________________________________

Full business address of the location at which the _____________________________________________________

patient consulted the Health Care Practitioner _____________________________________________________

(If different than above): _____________________________________________________

Patient’s First & Last Name: (Please print) _____________________________________________________ (Name on Application Form and Medical Document must match) Patient’s Date of Birth: Month:_____________ Day:____________ Year:____________

Daily quantity of dried marihuana to be used by the patient: ____________ g/day

The period of use is _______day(s) or ________ week(s) or ________ month(s). NOTE: The period of use cannot exceed one year

Medical Diagnosis (Optional):______________________________________________________________________________

OFFICE USE ONLY:

Verification Date completed:__________________________ Name of Clinic Staff:__________________________ Admin Initials:______________________

When faxing the original Medical Document to Delta 9 from the business fax number listed above, the faxed copy will now constitute as the original. Your retained Medical Document is now a copy for your records, and will not be distributed to any party, other than Delta 9.

By signing below, the health care practitioner is attesting to the above statement, and that the information contained in this

document is correct and complete.

Health Care Practitioner’s Signature (Required): _____________________________________________________

Date Signed (This is the date the period of use begins): Month:_____________ Day:____________ Year:____________

How do you prefer we contact you for the verification of this document: Phone ______ Fax ______ Email ______

□Check this box if the Health Care Practitioner consents to receive dried marihuana on behalf of the patient at the business address listed above.

□Check this box if the Health Care Practitioner consents to receive dried marihuana on behalf of the patient at the consultation address listed above.

Note: Shipping address on patient application form, must match the address that has been checked above.