Patient ID:

Daily Remaining

30 Day Cycle Remaining

0g of 0g

Prescription Expiry

Status

Inactive

Physician Notes

Chronic Pain Research OK

Voicemail OK

Aboriginal

Save Notes

Medical Document

Prescription

Quantity (grams/day) Quantity (grams/day)

Duration Duration

Period

Default THC Limit - Optional (Other empty THC fields mean use default THC limit) Default THC Limit - Optional (Other empty THC fields mean use default THC limit)

No Limit

Medical Diagnosis

Clinic

The amount of dried cannabis or cannabis oil to be used by the patient must be expressed in terms of total grams of dried cannabis authorized daily.

Prescribe Products

Dried Cannabis

Dried Cannabis Limit Dried Cannabis Limit

No Limit

Cannabis Extract - Inhalation

Cannabis Extract - Inhalation Limit Cannabis Extract - Inhalation Limit

No Limit

Cannabis Extract - Ingestion

Cannabis Extract - Ingestion Limit Cannabis Extract - Ingestion Limit

No Limit

Cannabis Topicals

Cannabis Topicals Limit Cannabis Topicals Limit

No Limit

Edibles - Ingestion

Edibles - Ingestion Limit Edibles - Ingestion Limit

No Limit

Product	Description	THC (mg/unit)	CBD (mg/unit)
CBD Soft Chews	High CBD	< 1	20
Balanced Soft Chews	1:1 THC:CBD	5	5
THC Soft Chews	High THC	5	< 1

Consultation Address

Applicable?

Yes No

Address Line 1 Address Line 1

Address Line 2 Address Line 2

City City

Province

Postal Code Postal Code

Referrals Option

Referred By Clinic

Referred by Practitioner

Referred By 3 Referred By 3

Referred By 4 Referred By 4

Referred By 5 Referred By 5

Patient's Information

Given Name Given Name

Surname Surname

Birth Date (MMM-DD-YYYY) Birth Date (MMM-DD-YYYY)

Gender

Telephone (optional) Telephone (optional)

Email Email

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Lot Identification:
Production Facility:

Lot Release Date:
Cold Pasteurized:

Total Bacteria PASS

Total Yeast and Mold PASS

Bile-Tolerant Gram-Negative Bacteria PASS

E. coli PASS

Salmonella PASS

Total Aflatoxins (B1, G1, B2, G2) PASS