APPLICANT AGREEMENT

 

1. Cool Kind shall pre-screen Applications. Upon completion of the Application, the Applicant becomes a registered member of our consulting service. We will perform a preliminary assessment. Your Application will not be processed if we feel that you have no chance of being approved for Medical Marijuana, and you will not be charged our consulting service fee;

2.  Once the Applicant is approved, the next step is to provide payment so that we can book a video call with the Applicant and a registered practicing physician

      • process the Applicant’s ACMPR application with Health Canada after receiving their prescription (this application is required if they are growing their own cannabis, or if they are having someone grow it for them) AND/OR
      • submit the Applicant’s registration to use Cannabis with a Licensed Producer (LP) (this registration is required if they are purchasing from a qualified grower (aka LP))

Once Applicable fees are received from the Applicant either through PayPal or e-Transfer to
payment@Coolkind.ca;

3.  Cool Kind shall arrange a confidential interview by electronic means between the Applicant and a highly qualified physician authorized to approve the use of medical marijuana;

4.  Cool Kind provides advice on an ongoing basis regarding the best licensed producers and most appropriate strains of medical marijuana for the Applicant’s condition;

5.  Cool Kind shall provide automatic reminders when renewal of the Medical Document is imminent;

6.  All medical information shall be kept in strictest confidence. Cool Kind will never sell or allow access to the Membership roster except on orders of the police with a court-issued warrant;

Applicant Obligations

7.  By completing this application, Applicants undertake to be honest and forthright regarding their medical condition, and to openly disclose all other prescription and non-prescription medications to the Physician/Nurse Practitioner;

8. By completing this application, Applicants acknowledge that violation of the Physician-Patient contract shall immediately terminate this contract;

9. By completing this application, Applicants acknowledge that they are solely responsible for any violation of the Criminal Code or the Controlled Drugs and Substances Act;


Release, Acknowledgment & Indemnity For Patients seeking an ACMPR Medical Document

By completing this application I understand that this Release and Acknowledgment contains valuable information about possessing/cultivating and consuming prescribed medical cannabis and that the assessing Physician/Nurse Practitioner requires it to issue a medical document for the Access to Cannabis for Medical Purposes Regulations (ACMPR). I also understand that the consulting Physician/Nurse Practitioner will not be assuming primary care for me, but will only be recognized as my ACMPR prescribing Practitioner. I understand and agree to continue to regularly see my primary care Physician for my medical conditions on a regular basis and notify them of my medical use of cannabis.

By completing this application I confirm that the assessing Physician/Nurse Practitioner will be the only practitioner providing a medical document under the ACMPR for the purpose of possessing/cultivating and consuming medical cannabis.

By completing this application I agree not to make any claim or commence any legal proceedings against the assessing Physician/Nurse Practitioner, his/her practice, my family Practitioner or any other involved Doctors (such as specialists) in relation to:

  1. My use of cannabis as a medicine; and
  2. My Application or prescription for possessing, obtaining, and using medical cannabis.

I am well aware that Physicians/Nurse Practitioners generally agree that medical cannabis;

  • May distort perception (sight, sounds, time, touch);
  • May impair thinking, problem-solving coordination, memory and learning
  • May increase heart rate and decrease blood pressure
  • May produce anxiety, fear, distrust, or panic

I am aware that a medical history that includes conditions such as Schizophrenia, Atrial fibrillation, Heart attack or Stroke or daily use of blood thinners may result in a denial for my application to possess and consume medical cannabis. I am also aware that if pregnant, or planning to become pregnant, that medical cannabis should not be consumed during pregnancy or while breastfeeding.

I understand that cannabis is not an approved therapeutic drug in Canada and that there is a lack of consensus amongst Physicians/Specialists about:

  • The appropriate dose and medical use of cannabis
  • The risks of smoking medical cannabis, as smoking can cause lung disease damage like emphysema, chronic bronchitis, and COPD, as compared to vaporizing or ingesting medical cannabis. I will avoid mixing marijuana with tobacco.
  • The risk of burning extracted cannabinoids such as oils or hashish
  • The risk of pulmonary infections, including pneumonia, and respiratory cancer
  • The long-term health and psychological risks associated with the use of medical cannabis
  • The risk of triggering mental illness, such as bipolar mood disorder and schizophrenia
  • The risk of nausea and disorientation

I am further well aware that the above listed medical concerns are further compounded by the lack of consistency and uniformity in available medical cannabis products. With conventional drug products I generally consume a medication of a precisely known molecular quantity. I recognize that raw plant Medical Cannabis does not work this way.

I appreciate that I will get varying compositions of different cannabinoids and varying proportions of different cannabinoids from strain of plant to strain of plant and even, to a lesser degree, from plant to plant of the same strain. I further appreciate that there is a significant uncertainty regarding the consistency of the medical cannabis drug product I may medicate with which further complicates and compounds the practical issue of medicating with an inconsistent drug product like medical cannabis.

By completing this application I truly believe that treating my personal medical condition(s) with medical cannabis, can potentially, or has had, a positive effect and the benefits outweigh the risks associated with previous methods used and this is my personal decision to possess and consume medical cannabis.

By completing this application I consent to the disclosure, sharing and use of my personal health information by the assessing Physician/Nurse Practitioner, my Licensed Producer or Health Canada for the process of obtaining my Medical Document. The information will be used to contact and register me as a patient.

I am aware If you drive a vehicle on the road or operate machinery, do NOT do so:

  1. Within 4 (FOUR) hours of inhaling cannabis vapor or smoke,
  2. Within 6 (SIX) hours of eating or ingesting cannabis edibles or oil,
  3. Within 8 (EIGHT) hours of using, if you get euphoric or dizzy – “Stoned”

I hereby release Cool Kind, the assessing Physician/Nurse Practitioner, his/her clinic, my family Physician and any other involved Physicians/parties from any and all actions, claims, causes of actions, complaints (even by family and friends) and demands for damages, loss, or injury whatsoever arising directly or indirectly as a consequence to my use of medical cannabis and my application to possess and/or produce medical cannabis

I agree to safely store my marijuana so that no other person can access it either deliberately or accidentally. I am aware that young people (under 25) may experience psychosis after consuming marijuana and will ensure that no child or young person will be exposed to my medical marijuana either directly or indirectly. I will contact Poison Control immediately if any child gains access to my supply of medical marijuana.

CONSENT FOR TREATMENT

Preamble:
It is understood and has always been understood by me that all Physicians/Nurse Practitioners have an obligation to use their skill and expertise in deciphering the reasonable care and treatment for patients regardless of their medical condition. This obligation is not different in relation to Marijuana Treatment and the patient understands this principal.

Sections:

  1. I agree to consider and be guided by the treatment plan and recommendations of my healthcare practitioner who is supervising my care in relation to the use of marijuana.
  2. I understand and agree in keeping with the above noted provision (section 1) to consume only amounts/doses authorized and prescribed for me by my health care practitioner and therefore I agree not to consume any amount over and above that which has been prescribed for me.
  3. I am aware that it is my obligation and responsibility to advise immediately the health care practitioner of any possibly perceived side effects of the product.
  4. It is very important to understand and I do understand the importance and necessity to desist and abstain absolutely from using illegal/street drugs (Cocaine-powder or crack, heroine, Meth) or controlled substances such as morphine, narcotics, stimulants or anxiety pills not prescribed currently during the course of my marijuana treatment.
  5. In keeping with the above noted understanding in Section 4, I undertake to and shall advise my healthcare practitioner if I am presently at the time of my marijuana use authorization, using a prescribed controlled substance by another doctor.
  6. I do understand, accept and agree that my Physician/Nurse Practitioner may exercise the option to discontinue authorizing marijuana for my use temporarily until further notice if an assessment reveals that the medical risks or side effects manifested during the course of my treatment are so significant that they (risks and side effects) out-weigh the beneficial result from such use.
  7. I recognize the importance and do agree to see any medical specialist or therapist to who I may be referred by my Physician/Nurse Practitioner in relation to my medical condition.
  8. It is understood that I have on my own volition chosen and decided to pursue the procedure requirements to obtain the use of marijuana for my medical condition. As such, I take full responsibility for risks associated with the use of marijuana and side effects I may experience. This section must be read together with section 4.
  9. Access:
    I understand that there is a legal requirement for me to obtain my marijuana from an authorized Licensed Producer or I may register with Health Canada to grow my own or have someone else grow it for me.

Use Electronic Communications

The Patient has agreed to communicate for consultations with the licensed Physician/Nurse Practitioner
named above using any of the following means of electronic communications services (ECS):

  • Email (specify):
  • Text messaging (including instant messaging)
  • Videoconferencing (check preferred):
  • Facetime WhatsApp
  • Skype Sylo
  • Videoconferencing: Medeo Virtual Care:
  • Other (specify): ie. Telephone calls

I acknowledge that I am actively aware of the risk implicit and explicit of the above noted electronic communication tools.

I understand the substantial risks of electronic communication generally and particularly of electronic mail (e-mail, text messaging) in that they can be intercepted by third parties or can be sent in error to parties other than for whom such communications was meant (i.e. the intending recipient).

I acknowledge and understand that despite recommendations that encryption software be used as a security mechanism for electronic communications, it is possible that communications with the Physician/Nurse Practitioner and Cool Kind ‘s staff using the Services may not be encrypted. Despite this, I agree to communicate with the Physician/Nurse Practitioner and Cool Kind’s staff using
these Services with a full understanding of the risk.

Risk of using Electronic Communication

I understand that the Physician/Nurse Practitioner and Cool Kind will use reasonable means to protect the security and confidentiality of information sent and received using electronic communication services but that the Physician/Nurse Practitioner and Cool Kind cannot guarantee the security and confidentiality of electronic communications.

Electronic communications can be forwarded, intercepted, circulated, stored, or even changed without the knowledge or permission of the Physician/Nurse Practitioner and Cool Kind or the patient.

Electronic communications may be disclosed in accordance with a duty to report or a court order. Videoconferencing using services such as Medeo, Skype, OTN may be more open to interception than other forms of videoconferencing. If the email or text is used as an e-communication tool, the following are additional risks:

Conditions of using Electronic Communication Services

While the Physician/Nurse Practitioner and Cool Kind will attempt to review and respond in a timely fashion to your electronic communication, the Physician/Nurse Practitioner and Cool Kind cannot guarantee that all electronic communications will be reviewed and responded to within any specific period of time. The Services will not be used for medical emergencies or other time-sensitive matters.

Electronic communications concerning diagnosis or treatment may be printed or transcribed in full and made part of your medical record. Other individuals authorized to access the medical record, such as staff and billing personnel, may have access to those communications.

The Physician/Nurse Practitioner and Cool Kind may forward electronic communications to staff and those involved in the delivery and administration of your care. The Physician/Nurse Practitioner and Cool Kind might use one or more of the Services to communicate with those involved in your care. The Physician/Nurse Practitioner and Cool Kind will not forward electronic communications to third parties,
including family members, without your prior written consent, except as authorized or required by law.

You agree to inform the Physician/Nurse Practitioner and Cool Kind of any types of information you do not want sent via the Services, in addition to those set you can add to or modify the above list at any time by notifying the Physician/Nurse Practitioner and Cool Kind in writing.

Some Services might not be used for therapeutic purposes or to communicate clinical information. Where applicable, the use of these Services will be limited to education, information, and administrative purposes.