Leaf Wise

Medical cannabis clinic in Alberta, Canada

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Patient Process
FAQ

Home
About
Patient Process
FAQ

REFERRAL FORM

To send us a referral, you can fill out the online form below or:

Fill out the form and email it to us

referrals@leafwise.ca

Fill out the form and fax it to us

1 (844) 573-WISE (9473)

You can view this form in: PDF

Medical Cannabis Referral Form

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Patient Information

First Name

Date of Birth*

Date ×

Email Address

Last Name

Healthcare #

Phone

Address:

Reason for Assessment*

Auto-Immune Disease

Mental Health Condition

Cancer

Seizure Disorder

Chronic Pain Condition

Sleep Apnea

Gastro-Intestinal Disorder

Other (please specify)

Write here

Primary Diagnosis and Physician Comments*

Write Here

Conventional Treatments Have Been Tried? *

YES

Current & Previous Treatments*

include medications for primary diagnosis

Write Here

Please Indicate a History or Presence of*

Active or unstable cardiovascular disease

Psychotic disorder (including schizophrenia)

Asthma/COPD

Substance abuse or dependence

Pregnancy (or trying to get pregnant)

Uncontrolled hypertension

Clinic & Referring Physician

Clinic Name

Name:

Fax Number

Fax

Referring Physician

Name

Clinic Phone Number

Phone

Clinic Address

Address

Prac. ID

Please provide a copy of all medical records pertaining to and supporting the primary diagnosis including medication history, recent investigations, consultation report, diagnostic imaging reports and prior treatments.

Your form has been submitted.

Thank you %NAME% for filling up the form.
we will get back to you as soon as possible.

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