Copy, paste, then print these forms and mail to the address listed at the bottom of the page.

 

  

 

Mobile Access Compassionate Resources Organization Society

Declaration of "informed consent" and  Membership Application

I, _______________________________________________, declare that I am invoking the "common law" doctrine of "informed consent" in choosing to use "Cannabis" as medicine.

I affirm that : (please circle and initial the statements which apply to your situation)

1. I am not less than 18 years of age (Initial)

2. I am a parent or guardian of a minor child that requires cannabis. (Initial)

3. I am an emancipated minor over the age of 16 years. (Initial)

I have informed my physician about my choice to use cannabis as for medical reasons, as well as how much I use and how effective it is as treatment for my illness.

Please State the ILLNESS being treated with Cannabis. ________________________________________________

Physician's name:_________________________

Address: __________________________________________

Telephone:__________________ Fax:____________________

I hereby release my doctor/physician to disclose/acknowledge to the Mobile Access Compassionate Resources Organization Society my choice to use "Cannabis" as medicine.

I accept full responsibility for my choice to use cannabis for medical reasons.

Signature of Applicant: ___________________________________

Address Telephone

Date:_______________________________

Signature of Witness: ___________________________________

Date:_______________________________

 
     

Notice of choice of medical treatment

Attention Doctor _______________________________________ ;

Pleased be advised that I, _______________________________; am

officially informing you of my decision to use Cannabis/Marijuana for

medical reasons to treat the following ailments/symptoms:

________________________________________________________

Be advised that I use __ grams per day as required in the following forms:

1._____ grams per day inhaled (smoked or vaporized)

2._____ grams per day orally (eaten)

3._____ grams per day orally (steeped in hot water as a tea)

This notice is to give you adequate information about my choice of medication so that you may continue to treat me and my present ailments and future medical problems as safely as possible with a minimum negative interaction to present and future proposed medical treatment, and for a legal excuse to be in possession of Cannabis should the need arise until such time as I obtain federally exempted status under the MMAR .

______________________________________________________________

(patient’s name, address and telephone) please print

__________________________________________(patient’s signature)

____________________________________________(witness signature and printed name)

Received by__________________________________________________

(Physician’s signature of receipt of notice and stamp) (Physician’s signature is not considered as endorsement or recommendation or prescription for cannabis use but is only to affirm receipt of this notice)

  
       
      You can also download the "Application Form" PDF file here and send via Canada Post to:

MACROS
Box 126, Edmonton Main
Edmonton, AB
T5J 2G9
Download Application PDF
Click Here
(PDF Format)
Download Medical NoticePDF
Click Here
(PDF Format)
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