Fillable MEDICAL DOCUMENT HEALTH CARE PRACTITIONER INFORMATION All elds

Fill Online, Printable, Fillable, Blank MEDICAL DOCUMENT HEALTH CARE PRACTITIONER INFORMATION All elds Form

Use Fill to complete blank online OTHERS pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

MEDICAL DOCUMENT HEALTH CARE PRACTITIONER INFORMATION All elds

On average this form takes 8 minutes to complete

The MEDICAL DOCUMENT HEALTH CARE PRACTITIONER INFORMATION All elds form is 2 pages long and contains:

  • 0 signatures
  • 1 check-box
  • 33 other fields

Country of origin: OTHERS
File type: PDF

BROWSE OTHERS FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
HEALTH CARE PRACTITIONER INFORMATION All fields marked with * are mandatory.
MEDICAL LICENSE INFORMATION
MEDICAL DOCUMENT
PRACTITIONER FIRST NAME*
MEDICAL LICENSE NUMBER*
BUSINESS ADDRESS*
CITY*
PHONE NUMBER*
PROVINCE*
FAX
POSTAL CODE*
EMAIL
PROFESSION*
PRACTITIONER LAST NAME*
PROVINCE(S)*
NAME OF OFFICE OR CLINIC*
IMPORTANT:
This form must be completed by a Physician or Nurse Practitioner
who is licensed in Canada. If another document is used in place of
this one, it must contain all of the information below.
Place stamp within the box, or fill out the information below.
If you use a stamp, please ensure that all of the mandatory information below is provided.
Province(s) in which you are licensed to practice.
PAGE 1/2
ACKNOWLEDGEMENT OF PHYSICIAN
DOSAGE
PATIENT INFORMATION
ADDRESS OF CONSULTATION
SIGNATURE* DATE (MM/DD/YEAR)*
The address at which the consultation took place between the applicant and the health care practitioner.
If neither of the above options apply, please provide the address at which the consultation took place below:
The period of use cannot exceed one year and will begin on the day the document is processed.
THE CONSULTATION TOOK PLACE AT THE
BUSINESS ADDRESS ABOVE
G/DAY DAYS WEEKS MONTHS
THE CONSULTATION TOOK PLACE VIA
INTERNET (SKYPE, ETC.)
IF NEITHER, PLEASE PROVIDE
THE ADDRESS BELOW
I attest that the information contained in this document is correct and complete. If submitted by secure fax, the faxed document received is
now the original medical document and this document will be a copy, retained for my records only.
Submit your original medical document along with your application form by one of the following methods:
BY CANADA POST TO:
3695 Drinkwater Rd.
Duncan, BC
Canada V9L 0E9
BY COURIER TO:
3695 Drinkwater Rd.
Duncan, BC
Canada V9L 0E9
BY SECURE FAX TO:
1-844-860-1194
BUSINESS ADDRESS
CITY PROVINCE POSTAL CODE
PATIENT FIRST NAME*
NUMBER OF GRAMS TO BE USED PER DAY* DURATION OF DOSAGE* (maximum 12 months)
DATE OF BIRTH (MM/DD/YEAR)*PATIENT LAST NAME*
(please circle either days, weeks or months)
BROKEN COAST CANNABIS
3695 DRINKWATER RD. DUNCAN,
BC V9L 0E9
INFO@BROKENCOAST.CA
TEL 1-888-486-7579
FAX 1-888-486-6384
PAGE 2/2
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

MEDICAL DOCUMENT HEALTH CARE PRACTITIONER INFORMATION All elds

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 10 August 2021

Message

View Audit Log
Print With Audit Log
Duplicate Document