Cannabinoid Medical Clinic-Physician Referral Form

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Physician Referral Form
Toll Free Phone: 1-888-282-7763
Toll Free Fax: 1-844-320-9652
Patient Information:
Name: ___________________________
DOB: _______________
Health Card # _________________________
Address: _________________________
City: _______________
Postal Code: __________________
Phone: (W) _______________________
(H)__________________
(C) _____________________
Email (required): _______________________________________________________
Referral to Service:
☐ Assess suitability for Medical Cannabis
☐ Other ______________________________________
☐YES
☐ NO
Is patient taking anti-coagulants?
☐YES
☐ NO
Is the patient pregnant, or trying to become pregnant?
☐YES
☐ NO
Does the patient have a significant communicable disease? (HIV, Hepatitis, ect.)
☐YES
☐ NO
Does the patient have untreated substance abuse/addiction?
Systemic/Other:
 Chronic pain: iatrogenic, operative, post traumatic
☐ Cancer
________________________
(specify)
 Immunological condition
(specify)_________________________
 Osteoarthritis
 Inflammatory Polyarthropathy (RA, Gout, other arthritis)
 Spondyloarthropathy
 Neurodegenerative disease
__________________
(specify)
 Fibromyalgia
 Has the patient been assessed by a Pain Specialist,
 Neuropathic Pain
Neurologist, Rheumatologist or Oncologist
 Other:___________________________________
Mental Health:
 Anxiety/Depression
 PTSD
 Sleep disorder
 Has the Patient been assessed by a Psychiatrist, GP/Psychotherapist or Clinical Psychologist?
Current Medications:
__________________________________________________________________________________________________
Medications tried for current condition:
__________________________________________________________________________________________________
Physician Information:
☐YES ☐ NO
Are you a member of a FHO/FHN/FHT? (Ontario Physicians ONLY)
Referring Physician: _________________________________
Phone: ________________
Fax: _____________________
Referring Physician Signature: __________________________________
Date: _________________
Billing# ______________________
Prac.ID# _______________________
Please Select a Clinic:
☐ Telemedicine
☐ Calgary, AB
☐ Edmonton, AB
☐ Winnipeg, MB
☐ Barrie, ON
☐ Burlington, ON
☐ Hamilton, ON
☐ Ottawa, ON
☐ Stoney Creek, ON
☐ Toronto, ON
☐ St. John’s, NL
☐ Halifax, NS
Please attach any relevant medical history, all pertinent scans and imaging
and any pertinent consults from other physicians or specialists.

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