By signing this document, you acknowledge that you have been informed of and
understand the following:


1. The physicians, 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 physician or clinic staff will NOT be providing or discussing information regarding any other way of obtaining medical marijuana other than from a Health Canada approved licensed producer.

4. If you are a BC resident, clinic staff will review your PharmaNet information. You are required to complete the “Patient Consent to Access PharmaNet” form found at this link:

5. The physicians are 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.

6. 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.

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

8. Should the physician 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.

9. 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.

10. Health Canada, the physicians and the Canadian Cannabis 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.

11. 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.

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

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

14. 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.

15. 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.

16. The physicians and/or the Canadian Cannabis Clinic staff will inform you of alternatives to smoking marijuana.

17. 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.

18. 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 the Canadian Cannabis Clinic.

19. 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.

20. If the Canadian Cannabis Clinic 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 Canadian Cannabis Clinic and/or provide additional information in the event of any inaccuracies or misstatements in the information you have provided.

21. Recommendations made by the Canadian Cannabis Clinic about Licensed Producers, strains and methods of intake are recommendations ONLY. The Canadian Cannabis Clinic 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 the Canadian Cannabis Clinic.

22. If you do not understand any of the above, you agree to contact the Canadian Cannabis Clinic for clarification.

23. The Canadian Cannabis Clinic is a private clinic that charges a fee for service. The clinic has a 7 day cancellation policy. Failure to cancel your appointment within the 7 days will result in a $200.00 charge. To cancel an appointment, you must speak directly with one of the clinics medical office assistants. Cancellations by email or phone message will not be accepted.

24. I authorize any Canadian Cannabis Clinic physician to make direct contact with a current, treating primary care physician to determine whether excessive use of marijuana has harmed myself, the patient.

25. I understand that the information I have been asked to provide to the Canadian Cannabis Clinic and/or the Physician 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.

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 the Canadian Cannabis Clinic.

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 through or reports about lawful and unlawful user activities on the Web site. 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.

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