RELEAF
Compassion Centers
Helping people help themselves
www.releafcompassioncenters.com
#106 - 20505 Fraser Hwy. #205-15220 Pacific Ave.
Langley, BC V3A 4G3 White Rock, BC V4B 1P7
Tel:(604)534-8993 Fax:(604)530-2519 Tel:(604)541-8223 Fax:(604)530-2519
Dear Health Care Practitioner,
Your patient is requesting membership with RELEAF Compassion Centers. RELEAF was created to bridge the gap between medicinal marijuana use and access.
RELEAF offers consultation and counselling combined with compassionate support and access to safe, clean, high quality, affordable medical marijuana for those with medical need.
As part of the orientation at RELEAF, members learn about the safe and effective use of marijuana, strain selections and a variety of alternative delivery methods/systems available to them, such as vaporization, edibles and tinctures.
An increasing number of medical practitioners recognize the effectiveness of cannabis in their patient’s treatment, and are referring their patients to us.
However, in order to maintain the level of legitimacy expected from our organization, RELEAF requires a confirmation of diagnosis and/or recommendation from a Physician or Nurse Practitioner as a condition of membership.
Please fill in the attached Practitioner’s Statement and fax it our office. If you feel uncomfortable recommending cannabis due to medical, legal, or other concerns, please indicate this in the space provided. If you only feel comfortable confirming your patient’s diagnosis, you may do so on our form or fax us a confirmation of your patient’s diagnosis with the date and your name and signature on your letterhead or a prescription pad. We will call you to verify that the fax did indeed come from your office.
RELEAF does not offer physician referrals. All information provided will be held to the strictest level of privacy by the management and staff of the RELEAF Compassion Centers.
Please feel free to contact us for any further information.
Respectfully,
Tara Caine – Care Worker/Advocate
RELEAF Compassion Centers
RELEAF Membership # ______
Compassion Centers
Helping people help themselves
www.releafcompassioncenters.com
#106 - 20505 Fraser Hwy. #205-15220 Pacific Ave.
Langley, BC V3A 4G3 White Rock, BC V4B 1P7
Tel:(604)534-8993 Fax:(604)530-2519 Tel: (604)541-8223 Fax:(604)530-2519
Patient’s name: ______
DOB: ______Tel/Cell: ______
I am willing to confirm that:
Mr. /Mrs. /Ms. ______has been diagnosed with ______
______and is presenting symptoms of ______
______
Please check all that apply:
___I recommend medicinal marijuana to my patient
___This patient has stated that her/his symptoms are helped by the use of medicinal marijuana and therefore, based on this knowledge, s/he ought to have access to it
___This patient has reported that her/his symptoms are helped by the use of medicinal marijuana
___I do not recommend the use of medicinal marijuana by this patient for the reasons stated below:
___ Medical: Please explain ______
___Legal: Please explain ______
___Other: Please specify ______
Practitioner’s signature: ______
Print name: ______
Date signed: ______
Practitioners phone # ______
Practitioners address: ______
______
Practitioners stamp/license:
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