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NOTE: form- (A1-A2)or(B1-B2)-"MUST" have form (C)attached


The Marsh Marijuana Club is a members only club,our address will only be revieled to registered members.All medical forms will be processed for us by a volunteer complying with our privacy act.Medical forms only PLEASE. For questions please direct them to the club e-mail.Thankyou

FORM PROCESSING


387 AGAR AVE
BRADFORD,Ont. Ca.
L3Z-1H6



Form A1.

Dear Physician,

The Marsh Marijuana Club. is a non-profit resource centre established for the benefit of people suffering from incurable conditions such as HIV, AIDS, cancer, multiple sclerosis,muscular dystrophy, glaucoma, epilepsy, arthritis, intractable pain, paraplegia and quadraplegia.

Your patient is requesting a letter of diagnosis from you on our behalf. The purpose of the letter is simply to document for our records that this person has been diagnosed with one of the above-mentioned ailments.

Please keep a copy of this letter and the accompanying Release of Confidential Medical Information in your patient's file as someone from The Marsh Marijuana Club. will call to quickly verify the validity of the letter.


The Marsh Marijuana Club.

Bradford, Ont. Ca.

Ph.905-775-1652

e-mail-scratchy@netcom.ca


Administor:________________________


Form A2

Dated:___________
Dear Marsh Marijuana Club.,

This letter is to certify that _____________________ has been diagnosed with_____________________.

I am a licensed physician permitted to practice medicine and write prescriptions in the province of Ontario. I understand that myself or my office will be contacted by telephone to verify this information.

Physician:____________________________



Form B1.


Dear Physician,


The Marsh Marijuana Club. is a non-profit resource centre established for the benefit of people whose lives are, or may be, improved dramatically by the use of cannabis.

This group includes those suffering from such serious conditions as HIV, AIDS,cancer, multiple sclerosis, muscular dystrophy,glaucoma, epilepsy, arthritis,intractable pain, paraplegia and quadraplegia among others.

Your patient is requesting a letter of diagnosis from you on our behalf. The purpose of the letter is simply to document for our records that this person has been diagnosed with a serious ailment and that their doctor feels that cannabis may have therapeutic value for them.

We have provided a sample letter for you to use as a guide. We would prefer your letter to be typed on official letterhead.

Please keep a copy of this letter and the accompanying Release of Confidential Medical Information in your patient's file as someone from The Marsh Marijuana Club. will call to quickly verify the validity of the letter.


The staff of The Marsh Marijuana Club.

Bradford, Ont. Ca.

Ph.905-775-1652

e-mail-scratchy@netcom.ca


Administor:________________________




Form B2


Dated:_________


Dear The Marsh Marijuana Club.


This letter is to certify that ________________________has been diagnosed with____________________________ and that I as ________________'s physician feel that cannabis may be beneficial to him/her.

I am a licensed physician permitted to practice medicine and write prescriptions in the province of Ontario. I understand that myself or my office will be contacted by telephone to verify this information.

Physician:______________________



Form C


Release of Confidential Medical Information

Date:_____________


I, ___________________________ , do hereby grant permission for the release of my confidential medical information to The Marsh Marijuana Club. I give permission for the physician noted below to verify my medical status with a staff member of The Marsh Marijuana Club.by telephone.
The Marsh Marijuana Club agrees to use this information for the sole purpose of determining eligibility and also agrees to keep this information strictly confidential.

Signature:_______________________

Physician________________________:

Physician's phone number:_________________