Online Consultation There are several sections to complete. Please take your time to answer carefully, as errors may cause lengthy delays or additional fees. Step 1 of 6 - Identity 0% Section 1: IdentityFirst name, as it appears on your government-issued ID*Last name, as it appears on your government-issued ID*Middle name(s)Date of Birth* MM DD YYYY Health Card Number*Gender*MaleFemaleOther/Prefer not to sayYour complete address, including postal code*Your Email Address* Phone Number*A phone number where you can be reached by our team of Doctors and SpecialistsGovernment-issued ID*Please upload a photo of the front and back of any Government-issued ID, matching the name you entered above. Drop files here or Accepted file types: jpg, gif, png, pdf, jpeg. Referral CodeIf you were provided a referral code, please enter it here.Agree* I agree this section has been completed truthfully. Section 2: Medical ProfileDescribe your primary medical conditions (ie., chronic back pain)*For how long?Your heightYour weightYour current Doctor or Specialists nameDescribe any therapy or treatment you currently do for your condition(s)Please list any and all medications you currently takePlease list any known allergiesAgree* I agree this section has been completed truthfully. Section 3: Opioid Risk AssessmentDo you have family history of: Alcohol Abuse Illegal Drug Abuse Prescription Drug Abuse Do you have personal history of: Alcohol Abuse Illegal Drug Abuse Prescription Drug Abuse Have you ever been diagnosed with, or experienced: Preadolescent Sexual Abuse Attention Deficit Disorder Obsessive Compulsive Disorder Bipolar Disease Depression Have you ever been diagnosed with Schizophrenia?*YesNoAgree* I agree this section has been completed truthfully. Section 4: Cannabis as MedicineWhy is Cannabis an effective/appropriate medical treatment for you?*How long have you been using Cannabis?*What is your preferred method(s) of consuming Cannabis?* Inhalation / Smoking Orally / Eating Topical / Creams Other How much Cannabis do you intend to consume on a daily basis?*Our consultation fee varies based on the daily consumption quantity.Up to 30 grams per dayUp to 90 grams per dayUp tp 120 grams per dayWhy would you say it is medically appropriate for you to grow/consume that quantity?*Have you ever received authorization to produce medical cannabis in the past?*YesNoHow many grams were you authorized for?Please provide your previous licence numberAgree* I agree this section has been completed truthfully. Section 5: LegalRelease, Acknowledgement & Indemnity Agreement for Patients seeking a Medical Cannabis document By typing your name below or clicking "I agree", you legally indicate your understanding and acceptance of the following:1*I, (type your name), understand that this Release and Acknowledgement contains valuable information about possessing/cultivating and consuming prescribed medical cannabis, that the assessing specialist/physician requires to issue a medical document for the access to cannabis for medical purposes regulations (ACMPR). I also understand that the consulting specialist/physician will not be assuming primary care for me, and will only be recognized as my ACMPR prescribing practitioner. I understand and agree to continue regularly seeing my primary care physician for my medical condition(s) on a regular basis and agree to inform them of my medical cannabis use.2*I confirm that the assessing specialist/physician will be the only practitioner providing a medical document under the ACMPR for the purpose of possessing/cultivating and consuming medical cannabis. I agree 3*I agree to make no claims or commence any legal action against the assessing physician/specialist/representative, my family physician, or any other involved person(s) in regards to both my consumption of medical cannabis and my application or medical document(s) for possessing, obtaining, cultivating and consuming medical cannabis. I agree 4*I am fully aware that specialists & physicians generally agree that medical cannabis may affect sight, sounds, and the sensation of touch. It may impair thinking, problem solving, coordination, memory or learning. Medical cannabis may increase heart heart and reduce blood pressure, and could induce fear, anxiety, distrust or panic. I agree 5*I am fully aware that medical conditions such as schizophrenia, atrial fibrillation, heart attack/stroke or use of blood thinners may result in the denial of my application to possess and consume medical cannabis. I am also aware that if pregnant or planning to become pregnant, medical cannabis should not be used during breastfeeding. I agree 6*I am aware of the considerable debate and lack of consensus among physicians/specialists regarding the following topics: The appropriate dose and medical use of cannabis. The risks of burning medical cannabis compared to vaporizing or ingesting. The risks of burning extracted cannabinoids such as oil or hashish. The long term risk psychological and health risks associated with medical cannabis. The risks of pulmonary infections and respiratory cancer. The risks of triggering mental illness, such as bipolar disease or schizophrenia. The risk of nausea and disorientation. I agree 7*I consent to the disclosure, sharing and use of my personal information and my personal health information by the assessing specialist/physician, and my licensed producer. The information may be used to contact and register the patient, and may also be used anonymously for analytical and research purposes. I agree 8*I truthfully believe that treating my personal medical condition(s) with medical cannabis potentially or has had a positive effect, and the benefits outweigh the potential risks associated. It is my personal decision to possess and consume medical cannabis and I do not support any claims made by family, friends, or other individuals against FastCann or the prescribing specialists/physicians. I agree 9*I hereby release The Green Key Ltd, our partners, the prescribing specialist/physician, other employees or team members, from any and all claims, actions, causes of actions, complaints (including friends and family), and demands for damages, losses, or injury arising directly or indirectly from my use of medical cannabis and/or my application to possess, cultivate, or consume medical cannabis. I agree 10*If licensed, I agree not to resell or give away any of my medication. I have read and understand the limitations and regulations set forth by Health Canada. I agree to check with local bylaws in my area. I also agree that any legal actions will take place in the province of British Columbia, and be governed by the laws of B.C., Canada. I agree 11*This release from liability is to be binding on heirs, executors, agents and attorneys. I acknowledge that I have the right to disagree to these terms, cancelling my application. I agree 12*I have carefully read and understood the questions and conditions on this form. I have double checked for errors, and my answers have been truthful. I agree PaymentThe Green Key collects a consulting fee that reflects the efforts of Medical Doctors, specialists, and a team of coordinators to assist you in the process of obtaining a grow licence. If we are unable to produce a medical document for you, these fees will be refunded.Grow up to 30 grams/dayThis licence enables you to grow 110 plants indoors, 29 plants outdoors, and store up to 10,875 grams of dried product. Price: $ 400.00 CAD Grow up to 90 grams/dayThis licence enables you to grow 329 plants indoors, 86 plants outdoors, and store up to 32,250 grams of dried product. Price: $ 850.00 CAD Grow up to 120 grams/dayThis licence enables you to grow 438 plants indoors, 114 plants outdoors, and store up to 42,750 grams of dried product. Price: $ 2,000.00 CAD Complimentary OrderThanks to our friends and partners, this consultation is on the house. Price: $ 0.00 CAD Subtotal $ 0.00 CAD Total $ 0.00 CAD Credit Card American ExpressDiscoverMasterCardVisa Card Number Month010203040506070809101112 Year20192020202120222023202420252026202720282029203020312032203320342035203620372038 Expiration Date Security Code Cardholder Name Questions? Contact Us Copyright (c) 2019, Vancouver Island Medical Marijuana Copyright (c) 2019, The Green Key Ltd.