Referral Form

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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

Patient Information

Clinic & Referring Physician

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.

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