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Patient Referral Form
9525 201 Street, Unit 218
Langley, B.C., V1M 4A5
T: 1-877-513-4769
F: 1-604-371-2044
E: info@greenleafmc.ca

Patient Referral Form

Referring Physician Information
Patient Information
Potential Indications For Cannabis
Mental Health Conditions
Gastrointestinal Conditions
Neurological/Pain Conditions
Cancer Conditions
Miscellaneous/Other Conditions
Please select medications that have been tried:
Does the patient have any UNCONTROLLED mania, schizophrenia, depression, or history of using sedatives/hypnotics/other psychoactive drugs?
DO SEND: Any injury or disease relevant imaging such as Xray, CT, MRI, etc. As well as relevant consults (psych, neuro, rheum and surgical.)

DO NOT SEND: Bloodwork results or medication list.
Upload Supporting Medical Documents (Only PDFs under 5MB):

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Physician Signature

Signature of Physician, Dated:

Use your mouse, finger or stylus to sign your name below.

NOTE: You will not be able to go back to edit the information on this form once it is submitted.