Membership Package Checklist
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- Maud Wheeler
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1 Membership Package Checklist Name: Date: Phone number: Please check that your membership package includes the following: Application for Registration signed and dated Code of Conduct read, checked boxes, signed and dated Photocopy of government issued photo ID Passport sized photo certified as likeness Physician's Statement* or copy of MMAR license DO NOT AFFIX PHOTO Included Has been/will be faxed * For the following conditions, only a confirmation of diagnosis is required. ADHD Depression Muscular Dystrophy AIDS/HIV Eating Disorders Nausea Chronic and debilitating Anxiety/Stress Disorder Eczema Neuralgia Arthritis Emphysema Paraplegia/Quadriplegia Asthma End of life/palliative care Psoriasis Brain/Head Injury Epilepsy Parkinson's Disease Cancer Fibromyalgia Radiation Therapy Cerebral Palsy Glaucoma Seizure Disorders Chemotherapy Treatment Hepatitis C Sleep Disorders Chronic Pain Irritable Bowel Syndrome Spinal Cord Injury Colitis Chronic Migraines Substance Addiction/Withdrawal Crohn's Disease Multiple Sclerosis All other diagnoses require a recommendation for the use of cannabis from your health care practitioner. Please note: when you pick up your card, you must show your photo ID. No exceptions. For office use only: Notes: Date of approval: Contacted by: phone or Fax Date: Membership number:
2 APPLICATION FOR REGISTRATION Applicant's Name: Address: City: Prov: Postal code: Phone number(s): Date of Birth E mail MMAR # (if applicable) Medical condition(s) and symptoms: Physician's name: Address: City: Prov: Postal code: Phone number(s): Optional: Are you presently taking any prescription pharmaceuticals? yes no If you answered yes, please list your drug regimen as well as any side effects: How long have you been using cannabis? How long have you been using cannabis as a medicine? How does cannabis affect your symptoms? How much/how often do you use cannabis? How did you hear about Grassroots Cooperative? I hereby declare that the information stated above is factual: APPLICANT'S SIGNATURE: DATE SIGNED: PRINTED NAME: All Dispensary members who provide an address will receive updates about medical marijuana activism. If you do not wish to receive s please check *GRASSROOTS COOPERATIVE RESERVES THE RIGHT TO LIMIT THE AMOUNT OF MEDICATION
3 CODE OF CONDUCT: PLEASE CHECK EACH BOX AFTER READING THE SECTION. VIOLATION OF THESE CODES OF CONDUCT WILL RESULT IN A TEMPORARY OR PERMANENT SUSPENSION OF SERVICES. NO RESELLING. NO SHARING. We provide medicinal cannabis for you only. Any reselling or sharing of your medicine is forbidden. If you are caught reselling any products purchased from the GBWC you will be permanently banned from receiving services. BE POLITE. We are doing our best to provide a service to our clients. Please treat the staff and other members of the GBWC with politeness and respect. BE RESPONSIBLE. Please use your medicine in a respectful and responsible way. Please do not smoke cannabis on the street or by our front door. Do not drive or operate heavy machinery if you are impaired by cannabis. KEEP US INFORMED. Please let us know about any quality issues you have with our products. Good or bad, please let us know what works and what doesn't work. DO NOT TRANSPORT ANY CANNABIS OUT OF CANADA. CAUTIONS: IMPAIRMENT: Cannabis may potentially cause a temporary decrease in coordination and cognitive abilities, and short-term memory loss while medicated. Do not drive or operate heavy machinery if impaired by cannabis products. Be especially careful of impairment when eating cannabis products or using extracts. Do not eat cannabis products before swimming or driving. ALCOHOL: Cannabis mixed with alcohol may cause vomiting and nausea. We recommend limiting or stopping your intake of alcohol when using cannabis products. IRRITATION: Heavy smoking with no harm reduction techniques may lead to respiratory irritation. BLOOD PRESSURE: Initial increase in heart rate and/or blood pressure may be problematic for those with heart conditions or severe anxiety. Those receiving digitalis or other cardiac medications should use cannabis under careful supervision by a medical doctor. WITHDRAWAL: There are no significant withdrawal effects when cannabis use is ceased or decreased, however minor restlessness, nausea, and fatigue may be experienced. Symptom relief will also cease or be decreased. THE LAW: It is still illegal in Canada to possess, grow, or distribute cannabis. Know your rights and take precautions to avoid the harmful effects of arrest, cannabis seizure, imprisonment and criminal record. ACKNOWLEDGEMENT: I accept that the GBWC makes no guarantees or medical claims, and I hereby agree for myself, my heirs and executors to waive any claims against the GBWC and its employees. I have read this form and agree to abide by the code of conduct and cautions listed above. Name: Signature: Date: Grassroots Cooperative reserves the right to terminate membership at any time. All documents submitted to Grassroots Botanicals Wellness Cooperative (GBWC) are the property of GBWC and are held in the strictest confidence.
4 Dear Health Care Practitioner, Your patient is requesting to receive services with the Grassroots Botanicals Wellness Cooperative (GRWC) has created safe and supportive access to high quality, organic, affordable cannabis for those in medical need. In order to maintain the level of legitimacy expected from our organization, GRB requires a confirmation of diagnosis and/or recommendation from a Physician, Naturopath or Doctor of Traditional Chinese Medicine as a condition of membership. As part of our orientation to GRB, members learn about the safe and effective use of cannabis and the variety of alternative delivery methods available to them, such as vaporizing, edibles and tinctures. We have attached some legal and medical information for you to read. For more information on the use of cannabis for specific symptoms and conditions, please check In the Canadian Medical Association Journal (issue 161(8), pg October 19, 1999), Dr. Morris Van Andel, then deputy registrar of the College of Physician's and Surgeons of BC, advises doctors to write a confirmation of a patient's medical condition rather than an illegal prescription. I would say 'I am writing to confirm that Mr. Smith is HIV positive and that he has indicated that his chronic pain is helped by marijuana and therefore should such a substance be available to him, that on the basis of my knowledge of him, he should be eligible for that type of help.' Please fill in the attached Practitioner's Statement and fax it to our office. If you feel uncomfortable recommending cannabis due to medical, legal, or other concerns, please indicate this in the space provided. If you only feel comfortable confirming your patient's diagnosis, you may do so on our form, or a confirmation of your patient's diagnosis with the date and your name and signature on your letterhead or a prescription pad. We will call you to verify that the fax did indeed come from your office. For more information, please contact us at In healing, Grassroots Botanicals Wellness Cooperative
5 Physicians Form Patient's name / / I am willing to confirm that Mr./Mrs./Ms. at phone number ( ) has been diagnosed with and is presenting symptoms of Please check the most appropriate statement: I recommend cannabis to help my patient with her/his symptoms. This patient has reported that her/his symptoms are helped by cannabis and therefore, on the basis of my knowledge, s/he should have access to it. This patient has reported that her/his symptoms are helped by cannabis. I do not recommend the use of cannabis for the reasons stated below: Medical: Please specify Legal: Please explain Other: please explain This patient is in a critical stage of their illness or treatment and requires immediate attention. My patient and I would like to be part of an ICM process with GBWC s social worker to monitor progress PRACTITIONER'S SIGNATURE: PRINTED NAME: DATE SIGNED: PRACTITIONER'S PHONE: PRACTITIONER'S ADDRESS:
6 The Canadian Medical Protective Association recommends to memberphysicians assisting patients in their application under the Marihuana Medical Access Regulations that they ask patient-applicants to sign a release from liability. The following form of release was developed and approved by The Canadian Medical Protective Association: I,, (print name of applicant) agree not to make any claim or complaint or commence any proceedings against Dr(s). (print name of physician signing the medical declaration) in relation to the application process under the Marihuana Medical Access Regulations or my use of marihuana. I release Dr(s). from any and all actions, causes of actions, claims, complaints and demands for damages, loss or injury whatsoever arising directly or indirectly as a consequence of my application under the Marihuana Medical Access Regulations or my use of marihuana. This release from liability is to be binding on my heirs, executors and assigns. Signature of Applicant Date Signature of Witness Date
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