PLEASE CHECK EACH BOX TO ACKNOWLEDGE YOU HAVE READ & UNDERSTAND THE TERMS
Violations of Green Care’s code of conduct will result in a temporary or permanent termination of membership.
☐ NO RESELLING NO SHARING. We provide medicinal cannabis for the sole use of qualified members. It is forbidden to
resell or share of your prescription. An infraction will result in a permanent ban to purchase medicinal products from
Cannaclinics.
☐ BE POLITE: We always do our best to provide superior service to our members. Please treat our staff and other
members respectfully.
☐ BE RESPONSIBLE: Please use your medicine in a respectful and responsible way. Please do NOT smoke cannabis on
the street or premises.
☐ KEEP US INFORMED. Please let us know about the quality of our products (positive or negative) and report any
adverse effects. Your feedback is key to helping us meet your specific needs.
☐ NEVER TRANSPORT CANNABIS PRODUCTS OUT OF CANADA.
☐ IMPAIRMENT: Cannabis may cause a temporary decrease in coordination, cognitive abilities and short-term memory
loss. Do not drive or operate heavy machinery while under the effects of cannabis. Be especially careful of impairment
when eating cannabis products or when using extracts. Do not eat cannabis products before swimming or driving.
☐ ALCOHOL: Cannabis mixed with alcohol may cause vomiting and nausea. We recommend that you limit or stop intake
of alcohol when under the influence of cannabis products.
☐ IRRITATION: Always use harm reduction techniques to prevent respiratory irritation.
☐ BLOOD PRESSURE: Initial increase in heart rate and/or blood pressure may be problematic for those with heart
conditions or severe anxiety. Those taking digitalis or other cardiac medications MUST always use cannabis under careful
supervision by a medical doctor.
☐ WITHDRAWAL: There are no significant withdrawal effects when cannabis use is ceased or decreased. Some people
experience minor restlessness, nausea and fatigue.
☐ THE LAW: It is still illegal in Canada to possess, grow or distribute cannabis. Know your rights and take precautions to
avoid the harmful effects of arrest, cannabis seizures, imprisonment and criminal record.
☐ CONFIRMATION OF DIAGNOSIS: Green Care will keep your note on file for your convenience. If you want a copy
there will be a $100.00 administration fee on top of the $10.00 consultation fee.
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CONTACT: Green Care Personnel will only contact you from the phone numbers and email listed on
www.greencaremed.ca. Any other contact with Green Care personnel is not sanctioned and will result in
your membership being revoked.
 I accept that Green Care makes no guarantees or medical claims. I hereby agree for myself, my heirs and
executors to waive any claims against Green Care and its employees.
☐ I have read this form and agree to abide by the code of conduct and cautions listed above.
☐ All sales are final.
Name:_______________________________Signature:______________________________ Date:__________________
Green Care
(778)-681-8694
[email protected]
www.greencaremed.ca