The World's First Medical Marijuana Farmers' Market by Health Canada Approved Designated Growers.TM

 Information Packages 

Please Print Form and complete in Blue or Black ink

Once completed and signed, your form is to be sent to at the following mailing address:

Membership Office at: 1769 St. Laurent Blvd, Suite 420, Ottawa, Ontario, K1G 5X7  Please include Cheque or Money Order made out to Dealer's Choice if needed.

After receiving your Signed Medical Documents, Get your ACMPR CARD within 24 hours 

Medical Document for the Access to Cannabis for Medical Purposes Regulations

This document may be completed by the applicant's health care practitioner as defined in the Access to Cannabis for Medical Purposes Regulations (ACMPR). A health care practitioner includes medical practitioners and nurse practitioners. In order to be eligible to provide a medical document, the health care practitioner must have the applicant for the medical document under their professional treatment. Regardless of whether or not this form is used, the medical document must contain all of the required information, (see in particular s. 8 of the ACMPR).

Patient's Given Name and Surname ___________________________________________

Patient’s Date of Birth (DD/MM/YYYY) ___________________________________________ Daily quantity of dried marihuana to be used by the patient: _________ g/day

The period of use is ______ day(s) _______ week(s) _______ month(s).

NOTE: The period of use cannot exceed one year

Health care practitioner's given name and surname: Profession:
Health care practitioner’s business address:

Full business address of the location at which the patient

consulted the health care practitioner (if different that above):

Phone Number:
Fax Number (if applicable):
Email Address (if applicable):
Province(s) Authorized to Practice in: 
Health Care Practitioner's Licence number:

____________________________________________ ____________________________________________ ___________

Bysigningthisdocument,thehealthcarepractitionerisattestingthattheinformationcontainedin thisdocument is correct and complete.

Health Care Practitioner's Signature: ____________________________________________ Date Signed (DD/MM/YYYY): ___________________________________________ 

NOTE: The medical document can be submitted from the health care practitioner’s office to by secure fax 1-855-4-zuubee (1-855-498-8233). If you choose to submit the medical document by secure fax, initial the statement below to acknowledge agreement.

I, the health care practitioner, acknowledge that the faxed medical document is now the original medical document and that I have retained a copy of this document for my records only.

Initial here: ______________

At we want to keep you Family Doctor informed on your Health Care and make sure there is no conflict with Medication you are currently taking, Your Health and safety is a Health Canada Priority page1image19480 page1image19640

Patient Information:This section must be filled out completely or your Access to Cannabis for Medical Propose Regulations(ACMPR) will be denied. You must read and understand "SERIOUS WARNINGS AND PRECAUTIONS FROM HEALTH CANADA"at 

1. Applicant’s Information

Mrs. Miss Ms. Mr.


Full name(last/first/middle):

Gender: M F X (person does not identify or associate with either gender)

Date of birth:

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Telephone number: Home Cellular


Fax number (if applicable):


Preferred Official Language: English French

2. Ordinary Place of Residence:


Address: (If no street address please write Lot or Concession number instead)

Apartment number:




Postal code:

Select what best describes the address you provided above:
Private residence – House Private residence – Apartment Private residence – Condo Not a private residence – Hospice Not a private residence – Hospital


If the address is not a private residence, please provide the name of the establishment:

Is the mailing address the same as the address of your ordinary place of residence?

(If No, please complete the Mailing Address portion below) This is the address that your medical marijuana will be mailed or delivered to.





Apartment number:



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Postal code:

4. I have included my medical document                                Yes______________ Initials         No ____________Initials.

If YES, please provide original copy, also provide Information Package Part 2  "Patient Form" All must be signed and sent by mail to 1769 St. Laurent Blvd, Suite 420, Ottawa, Ontario, K1G 5X7, Canada, Original Copy Only or your claim will be denied.

Medical Marijuana Growers Association of Canada is able and willing to launch a class action suit against Doctors that are only interested in prescribing opiates to patient, As a voting member of, would you support this action taken by Medical Marijuana Growers Association of Canada solely                           Yes_________________ Initials            No______________Initials

5.If no, I will be using to recommend a doctor, Medical Practitioners, midwife, nurse practitioner or podiatrist.  As per subsection 136(3) of the ACMPR, 

It is the individual's right to decide which licensed producer or designated grower will meet his/her needs for obtaining access to fresh or dried marijuana for medical purposes.

6. I herby acknowledge that I have read and understand all  "SERIOUS WARNINGS AND PRECAUTIONS FROM HEALTH CANADA" and read "Understanding the New Access to Cannabis for Medical Purposes Regulations From Health Canada"  I would still like to proceed with being a member of so I can have access to Health Canada approved designated growers cannabis and or be a Health Canada approved Designated Grower.

Applicant’s signature:



7.This Section is Optional

Production for Own Medical Purposes and Production by a Designated Person Registration

After step 3 or step 4 is completed you are now allowed to produce your own medical Marijuana,
Would you like to proceed to the Next STEP "Growing your own Medicine"  NO_______  YES________

 IF YOU INDICATED YES will send you the next forms that will have to be completed, for you to grow your own medicine. Only after STEP 3 or STEP 4 are completed.


8. Applicant’s Declaration and Signature. This section must be signed or you will be denied

Once your medical document is signed, you will recieve your own ACMPR card.

If you would like a 5 gram Sample Pack of Health Canada Approved Designated Growers Medical Marijuana to try for your medical condition, just add another $30.00 to your Cheque or Money Order, HST  included. We will send your Sample Pack and ACMPR card out at the same time.

page4image75525 gram Sample Packs are $30.00 hst included. Yes I would like a Sample Pack Yes______No_____

I attest that the information on this form is correct and complete.

Applicant signature:

Print name:


Good People Helping Good People

Please Mail to: Acmpr Membership Office 1769 St. Laurent Blvd, Ottawa, Ontario, K1G 5X7
After receiving your Signed Medical Documents, Get your ACMPR CARD within 24 hours