Mailing Address:
4730 Willingdon Ave, Powell River, BC, V8A 2N4
All Member Inquiries:
Tel: (604) 223-1357
Email: coop@grassrootscannabisdispensary.com
Membership Package Checklist
Name: _____________________ Date: ___________________________
Phone number: ____________________Email: ____________________________
Please check that your membership package includes the following:
☐ Application for Registration – signed and dated
☐ Code of Conduct – read, checked boxes, signed and dated
☐ Photocopy of government issued photo ID
☐ Passport sized photo – certified as likeness
Physician's Statement* or copy of MMAR license DO NOT AFFIX PHOTO
☐ Included
☐ Has been/will be faxed
* For the following conditions, only a confirmation of diagnosis is required.
ADHD
AIDS/HIV
Anxiety/Stress Disorder
Arthritis
Asthma
Brain/Head Injury
Cancer
Cerebral Palsy
Chemotherapy Treatment
Chronic Pain
Colitis
Crohn's Disease
Depression
Eating Disorders
Eczema
Emphysema
End of life/Palliative care
Epilepsy
Fibromyalgia
Glaucoma
Hepatitis C
Irritable Bowel Syndrome
Chronic Migraines
Multiple Sclerosis
Muscular Dystrophy
Nausea – Chronic and debilitating
Neuralgia
Paraplegia/Quadriplegia
Psoriasis
Parkinson's Disease
Radiation Therapy
Seizure Disorders
Sleep Disorders
Spinal Cord Injury
Substance Addiction/Withdrawal
All other diagnoses require a recommendation for the use of cannabis from your health care
practitioner. Please note: when you pick up your card, you must show your photo ID. No exceptions.
For office use only:
Notes:
_________________________________
_________________________________
_____________________
Date of approval:_____________
Contacted by:☐ phone or ☐Email
Date:___________
Membership number: ____________
Mailing Address:
4730 Willingdon Ave, Powell River, BC, V8A 2N4
All Member Inquiries:
Tel: (604) 223-1357
Email: coop@grassrootscannabisdispensary.com
APPLICATION FOR REGISTRATION
Applicant's Name:__________________________________________________________
Address:____________________________City:___________Prov:_______
Postal code:___________________Phone number(s):_______________________
Date of Birth__________________E-mail_________________________________
MMAR # (if applicable) _____________________________________________________
Medical condition(s) and symptoms:________________________________________________
______________________________________________________________________________
________________________________________________________________________
Physician's name: __________________________________________________________
Address: ________________________City:________________Prov:______
Postal code: __________Phone number(s):________________________________
Optional: Are you presently taking any prescription pharmaceuticals? yes☐no☐
If you answered “yes”, please list your drug regimen as well as any side effects:_____________
______________________________________________________________________________
________________________________________________________________________
How long have you been using cannabis?_______________________________________
How long have you been using cannabis as a medicine?___________________________
How does cannabis affect your symptoms?_____________________________________
________________________________________________________________________
How much/how often do you use cannabis?_____________________________________
How did you hear about Grassroots Cooperative? _____________________________
I hereby declare that the information stated above is factual:
APPLICANT'S SIGNATURE:____________________________________________
DATE SIGNED:________________________________________________________
PRINTED NAME:______________________________________________________
All Dispensary members who provide an email address will receive email updates about medical
marijuana activism. If you do not wish to receive emails please check ☐
*GRASSROOTS COOPERATIVE RESERVES THE RIGHT TO LIMIT THE AMOUNT OF MEDICATION
Mailing Address:
4730 Willingdon Ave, Powell River, BC, V8A 2N4
All Member Inquiries:
Tel: (604) 223-1357
Email: coop@grassrootscannabisdispensary.com
CODE OF CONDUCT:
PLEASE CHECK EACH BOX AFTER READING THE SECTION.
VIOLATION OF THESE CODES OF CONDUCT WILL RESULT IN A TEMPORARY OR PERMANENT SUSPENSION OF SERVICES.
NO RESELLING. NO SHARING. We provide medicinal cannabis for you only. Any reselling or sharing of your medicine is forbidden. If you are
caught reselling any products purchased from the VDS you will be permanently banned from receiving services.
BE POLITE. We are doing our best to provide a service to our clients. Please treat the staff and other members of the VDS with politeness and
respect.
BE RESPONSIBLE. Please use your medicine in a respectful and responsible way. Please do not smoke cannabis on the street or by our front
door. Do not drive or operate heavy machinery if you are impaired by cannabis.
KEEP US INFORMED. Please let us know about any quality issues you have with our products. Good or bad, please let us know what works and
what doesn't work.
DO NOT TRANSPORT ANY CANNABIS OUT OF CANADA.
CAUTIONS:
IMPAIRMENT:
Cannabis may potentially cause a temporary decrease in coordination and cognitive abilities, and short-term memory loss while medicated. Do
not drive or operate heavy machinery if impaired by cannabis products. Be especially careful of impairment when eating cannabis products or
using extracts. Do not eat cannabis products before swimming or driving.
ALCOHOL:
Cannabis mixed with alcohol may cause vomiting and nausea. We recommend limiting or stopping your intake of alcohol when using cannabis
products.
IRRITATION:
Heavy smoking with no harm reduction techniques may lead to 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 receiving
digitalis or other cardiac medications should use cannabis under careful supervision by a medical doctor.
WITHDRAWAL:
There are no significant withdrawal effects when cannabis use is ceased or decreased, however minor restlessness, nausea, and fatigue may be
experienced. Symptom relief will also cease or be decreased.
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 seizure, imprisonment and criminal record.
ACKNOWLEDGEMENT:
☐ I accept that the GBWC makes no guarantees or medical claims, and I hereby agree for myself, my
heirs and executors to waive any claims against the GBWC and its employees.
☐ I have read this form and agree to abide by the code of conduct and cautions listed above.
Name:________________________________________________
Signature:______________________________________________
Date:_________________________________________________
Grassroots Cooperative reserves the right to terminate membership at any time.
All documents submitted to Grassroots Botanicals Wellness Cooperative
(GBWC) are the property of GBWC and are held in the strictest confidence.
Mailing Address:
4730 Willingdon Ave, Powell River, BC, V8A 2N4
All Member Inquiries:
Tel: (604) 223-1357
Email: coop@grassrootscannabisdispensary.com
Dear Health Care Practitioner,
Your patient is requesting to receive services with the Grassroots Botanicals Wellness
Cooperative (GRWC) has created safe and supportive access to high quality, organic, affordable
cannabis for those in medical need.
In order to maintain the level of legitimacy expected from our organization, GRB requires a
confirmation of diagnosis and/or recommendation from a Physician, Naturopath or Doctor of
Traditional Chinese Medicine as a condition of membership.
As part of our orientation to GRB, members learn about the safe and effective use of cannabis
and the variety of alternative delivery methods available to them, such as vaporizing, edibles
and tinctures.
We have attached some legal and medical information for you to read. For more information
on the use of cannabis for specific symptoms and conditions, please check
http://safeaccess.ca/research.
In the Canadian Medical Association Journal (issue 161(8), pg. 1024 October 19, 1999), Dr.
Morris Van Andel, then deputy registrar of the College of Physician's and Surgeons of BC,
advises doctors to write a “confirmation” of a patient's medical condition rather than an illegal
prescription. “I would say 'I am writing to confirm that Mr. Smith is HIV positive and that he has
indicated that his chronic pain is helped by marijuana and therefore should such a substance be
available to him, that on the basis of my knowledge of him, he should be eligible for that type
of help.'”
Please fill in the attached Practitioner's Statement and fax it to our office. If you feel
uncomfortable recommending cannabis due to medical, legal, or other concerns, please
indicate this in the space provided. If you only feel comfortable confirming your patient's
diagnosis, you may do so on our form, or a confirmation of your patient's diagnosis with the
date and your name and signature on your letterhead or a prescription pad.
We will call you to verify that the fax did indeed come from your office.
For more information, please contact us at 604-223-1357
In healing,
Grassroots Botanicals Wellness Cooperative
Mailing Address:
4730 Willingdon Ave, Powell River, BC, V8A 2N4
All Member Inquiries:
Tel: (604) 223-1357
Email: coop@grassrootscannabisdispensary.com
Physicians Form
Patient's name
__________________________________________________________/______/___
I am willing to confirm that Mr./Mrs./Ms._____________________________________
at phone number (______)___________________
has been diagnosed with___________________________________
and is presenting symptoms of
____________________________________________________________________________
____________________________________________________________________________
Please check the most appropriate statement:

I recommend cannabis to help my patient with her/his symptoms.

This patient has reported that her/his symptoms are helped by cannabis and therefore, on the basis of my
knowledge, s/he should have access to it.

This patient has reported that her/his symptoms are helped by cannabis.

I do not recommend the use of cannabis for the reasons stated below:
Medical: Please
specify ________________________________________________________________________
______________________________________________________________
___________________________________________________________________
Legal: Please explain
_______________________________________________________________________________
_______________________________________________________________________________
___________________________________________
Other: please explain
_______________________________________________________________________________
_______________________________________________________________________________
___________________________________________


This patient is in a critical stage of their illness or treatment and requires immediate attention.
My patient and I would like to be part of an ICM process with GBWC’s social worker to monitor
progress
PRACTITIONER'S SIGNATURE:__________________________________________
PRINTED NAME:______________________________________________________
DATE SIGNED:________________________________________________________
PRACTITIONER'S PHONE:______________________________________________
PRACTITIONER'S ADDRESS:____________________________________________
Mailing Address:
4730 Willingdon Ave, Powell River, BC, V8A 2N4
All Member Inquiries:
Tel: (604) 223-1357
Email: coop@grassrootscannabisdispensary.com
The Canadian Medical Protective Association recommends to memberphysicians assisting patients in their application under the Marihuana
Medical Access Regulations that they ask patient-applicants to sign a
release from liability. The following form of release was developed and
approved by The Canadian Medical Protective Association:
I, ,
(print name of applicant)
agree not to make any claim or complaint or commence any proceedings against
Dr(s).
(print name of physician signing the medical declaration)
in relation to the application process under the Marihuana Medical Access Regulations or my
use of marihuana.
I release Dr(s).
from any and all actions, causes of actions, claims, complaints and demands for damages, loss
or injury whatsoever arising directly or indirectly as a consequence of my application under the
Marihuana Medical Access Regulations or my use of marihuana. This release from liability is to
be binding on my heirs, executors and assigns.
Signature of Applicant Date
Signature of Witness Date