Fillable PATIENT INFORMATION (College of Physicians & Surgeons of Alberta)

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PATIENT INFORMATION (College of Physicians & Surgeons of Alberta)

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Cannabis for Medical Pur
p
oses
Patient Medical Document
As there is limited evidence for the use of medical cannabis and significant potential for harm, physicians should be very
cautious in authorizing its use and do so only within the context of an established physician-patient relationship.
Physicians are required to complete this form and submit it to the College of Physicians & Surgeons of Alberta (CPSA) when
authorizing the use of cannabis for medical purposes by a patient in Alberta. The physician must be a registered authorizer of
cannabis with the CPSA and should review the Cannabis for Medical Purposes standard of practice and advice document prior to
authorizing cannabis use (http://bit.ly/med-cannabis-SoP
).
PATIENT INFORMATION
Surname:
Date of birth (DD/MMM/YYYY):
Given name(s):
Personal Health Number:
Indication for medical cannabis authorization:
(Refer to evidence-based indications as per http://bit.ly/med-cannabis-resources )
Dosing instructions: Amount of THC mg/day and/or Amount of CBD mg/day
Form of cannabis used: dried oil other:
Total Amount of Cannabis Authorized as per Health Canada Regulations: ________ gms/day
Duration of authorization: _ day(s) week(s) month(s)
(Note: The patient must be reassessed at least every three months while using medical cannabis. The duration of
authorization cannot exceed one year from the date of this document.)
PHYSICIAN INFORMATION
Registration/license number:
Surname:
Given name:
Province(s) licensed to practice in:
Business address:
Phone:
Fax:
Address where patient
is being treated:
Your relationship to the patient:
Family doctor
Consulting physician, specialty:
Referring physician:
Other:
I attest that the information on this form is correct and complete:
Physician’s signature:
Date:
SUBMIT FORM WITHIN ONE WEEK OF COMPLETION TO:
College of Physicians & Surgeons of Alberta
Fax: 780-429-1981 | Mail: 2700 - 10020 100 Street NW Edmonton, AB T5J 0N3
*
Physicians authorizing Cannabis are subject to the Cannabis Act and its Regulation. This information is being
requested as per s272(a) and s273 of the Cannabis Regulations (SOR/2018-144).
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PATIENT INFORMATION (College of Physicians & Surgeons of Alberta)

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Completed 4 May 2021

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