• I confirm I am a Canadian citizen, permanent resident or an aboriginal currently residing in Canada.
• I give consent to disclose my personal health information with Ausabis’s trusted healthcare professionals as is needed to process my application
• I agree to be treated by a healthcare team located in Canada.
The prescribing of medical cannabis is regulated by provincial guidelines, as well as the unique policies to your nurse practitioner’s practice. This agreement has been prepared to both inform you about medical cannabis therapy, as well as to document that you agreed to the rules and obligations contained within this agreement.
Below outlines your obligations of being a patient with AUSABIS GROUP:
1. I agree to take only my prescribed dose of medical cannabis.
2. I will not misuse my medical cannabis prescription in any way.
3. I will let my nurse practitioner know if I have any history of psychosis or a family history of psychosis.
4. I agree to provide a urine sample for a drug screen whenever I am asked. This may mean that I will have to provide the urine sample in the office of my family doctor. I understand that if I do not want my family doctor to know I am taking medical cannabis, I will be responsible to pay an additional fee in order to cover the cost of the drug screen.
5. I agree that, if I do a drug screen through my family doctor, my family doctor is permitted to share the results of my urine sample with AUSABIS.
6. I understand that tampering with my urine sample in anyway is a serious violation of the program and may affect my future status in the program.
7. I agree to complete any requested questionnaires, tests or screens that are deemed appropriate by my prescribing nurse practitioner.
8. I understand that it is important for me to inform any physician or dentist who may treat me for dental, medical or psychiatric conditions too the fact that I am receiving medical cannabis so that my treatment may be tailored to prevent potentially dangerous interactions with medical cannabis. I will bring any prescriptions or medication bottles from other doctors to appointments with my prescribing nurse practitioner at AUSABIS GROUP.
9. I understand that the nurse practitioner may cancel my prescription at any time if they deem it appropriate.
10. I am not presently in a substance abuse program.
11. I agree to purchase my medical cannabis from the Health Canada approved Licensed Producer (LP) I am registered with.
12. Once registered with a Licensed Producer I agree not to see another doctor or nurse practitioner for the purpose of obtaining another “Medical Document” in order to register with another Licensed Producer.
13. I agree to keep all my appointments with the nurse practitioner who is authorizing my medical cannabis. There will be a $50.00 cancellation fee for canceling appointments with less than 24 hours notice.
14. The nurse practitioner and/or AUSABIS GROUP is not obligated to fax any Medical Document without an assessment.
15. AUSABIS GROUP may use my personal health information (i.e. your condition(s) & product selection) on an anonymous and aggregate basis for research purposes or medical education purposes.
I authorize AUSABIS GROUP and my Licensed Producer to disclose both my cannabis purchasing and health information to each other, as required for each to provide their respective services to me. I agree to be automatically registered the LP(s) as agreed.
Regarding pregnancy, I understand that there can be effects on the developing fetus caused by medical cannabis and that special care will be required to reduce any harm to my fetus if I am or become pregnant while on medical cannabis. I am not currently pregnant and agree to inform my prescribing urse practitioner if I plan to be or think may be pregnant.
I understand it is unsafe to drive motor vehicle or operate machinery while intoxicated with alcohol, cannabis or other illicit substances.
You may experience side effects if you consume medical cannabis, especially if your medicine contains THC. Side effects include but are not limited to:
• Dizziness, drowsiness, feeling faint or lightheaded, fatigue, headache.
• Impaired memory, disturbances in attention, concentration and ability to think and make decisions.
• Disorientation, confusion, feeling “drunk,” feeling abnormal or having abnormal thoughts, feeling too “high,“ feelings of unreality, feeling an extreme slowing of time.
• Suspiciousness, nervousness, episodes of anxiety resembling a panic attack, paranoia (loss of contact with reality), hallucinations (seeing or hearing things that do not exist).
• Impairments in motor skills and perception, altered bodily perceptions, loss of full control of bodily movements, falls.
• Dry mouth, throat irritation, coughing.
• Nausea, vomiting.
• Fast heartbeat.
I agree to notify my treating nurse practitioner and family doctor if I develop any side effects and/or seek medical attention in anyway.
I acknowledge that the nurse practitioner I will be seeing today is NOT my primary care provider.
Medical cannabis treatment will be discontinued or tapered if my nurse practitioner determines that it has become medically unsuitable (i.e. the treatment is not effective or I develop a medical condition that could be made worse by Medical Cannabis treatment) or any of the obligations listed above are not followed.
I allow my medical cannabis nurse practitioner to speak to other doctors and healthcare professionals about my care.
I understand that I may not be seen for my visit for medical cannabis if:
1. I arrive late to my appointment: either in person or via telemedicine.
2. I exhibit threatening or disruptive behavior toward any staff member or another patient.
Everything that you tell our staff is confidential. However, it is important to realize that under exceptional circumstances we can be obligated to report something to the appropriate authority such as:
1. If we suspect a child is at risk: emotional or physical harm or neglect. Under the child and family services act, it is the law that we report this information.
2. If you become suicidal, homicidal or are unable to take care of yourself due to a psychiatric condition, you might be held against your will to be assessed by a psychiatrist.
3. If you revealed the staff that you intended to harm another person, we will be obligated to protect that person by notifying the appropriate authority.
4. If a court subpoenas your medical chart, we must release it in accordance to the subpoena.
5. If it is suspected that you were unable to drive due to a medical condition (such as alcohol or drugs), we are obligated to notify the Ministry of Transportation.
6. Certain infections must be reported to the local public health department such as tuberculosis, HIV, etc. Please refer to the Ministry of Health Canada for a full list.
I agree to respect the confidentiality of other patients in this program.
I give AUSABIS GROUP permission to communicate with me, as well as send/receive information by email and the secure patient portal.
I agree not to make any claim or complaint or commence any proceedings against healthcare providers contracted with AUSABIS GROUP in relation to the application process under the Access to Cannabis for Medical Purposes Regulations or my use of cannabis.
I release healthcare providers contracted with AUSABIS GROUP 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 Access to Cannabis for Medical Purposes Regulations or my use of cannabis. This release from liability is to be binding on my heirs, executors and assigns.
Should I fail to meet the terms of this agreement, I understand that I may be asked to leave the medical cannabis program. I have had the opportunity to discuss and review this agreement with my attending nurse practitioner and staff and all my questions have been answered.