copy and print
required forms
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:_________________