Renouvellement
de prescription

Name *

<font style="vertical-align: inherit;"><font style="vertical-align: inherit;">First name</font></font>

<font style="vertical-align: inherit;"><font style="vertical-align: inherit;">Last name</font></font>

Gender *

<font style="vertical-align: inherit;"><font style="vertical-align: inherit;">Male</font></font>

<font style="vertical-align: inherit;"><font style="vertical-align: inherit;">Feminine</font></font>

Date of birth *

<font style="vertical-align: inherit;"><font style="vertical-align: inherit;">Day</font></font>

<font style="vertical-align: inherit;"><font style="vertical-align: inherit;"> / </font></font>

<font style="vertical-align: inherit;"><font style="vertical-align: inherit;">Month</font></font>

<font style="vertical-align: inherit;"><font style="vertical-align: inherit;"> / </font></font>

<font style="vertical-align: inherit;"><font style="vertical-align: inherit;">Year</font></font>

Health insurance No. *

Expiration *

<font style="vertical-align: inherit;"><font style="vertical-align: inherit;">Day</font></font>

<font style="vertical-align: inherit;"><font style="vertical-align: inherit;"> / </font></font>

<font style="vertical-align: inherit;"><font style="vertical-align: inherit;">Month</font></font>

<font style="vertical-align: inherit;"><font style="vertical-align: inherit;"> / </font></font>

<font style="vertical-align: inherit;"><font style="vertical-align: inherit;">Year</font></font>

Have you changed your address in the past year?

<font style="vertical-align: inherit;"><font style="vertical-align: inherit;">Yes</font></font>

<font style="vertical-align: inherit;"><font style="vertical-align: inherit;">No</font></font>

If yes, specify the new address

<font style="vertical-align: inherit;"><font style="vertical-align: inherit;">Street number and name</font></font> <font style="vertical-align: inherit;"><font style="vertical-align: inherit;">City</font></font> <font style="vertical-align: inherit;"><font style="vertical-align: inherit;">Province</font></font> <font style="vertical-align: inherit;"><font style="vertical-align: inherit;">Postal code</font></font> <font style="vertical-align: inherit;"><font style="vertical-align: inherit;">Country</font></font>

Home phone *

Cellular (1)

E-mail

In the past year, has there been a change in the health professionals who follow you? *

<font style="vertical-align: inherit;"><font style="vertical-align: inherit;">Yes</font></font>

<font style="vertical-align: inherit;"><font style="vertical-align: inherit;">No</font></font>

If yes, specify

Have you had surgery in the past twelve months?

<font style="vertical-align: inherit;"><font style="vertical-align: inherit;">Yes</font></font>

<font style="vertical-align: inherit;"><font style="vertical-align: inherit;">No</font></font>

Have you received a new diagnosis in the past year or noticed any significant change in your health? *

<font style="vertical-align: inherit;"><font style="vertical-align: inherit;">Yes</font></font>

<font style="vertical-align: inherit;"><font style="vertical-align: inherit;">No</font></font>

If yes, specify

Have you tried any new drugs or treatments in the past year? *

<font style="vertical-align: inherit;"><font style="vertical-align: inherit;">Yes</font></font>

<font style="vertical-align: inherit;"><font style="vertical-align: inherit;">No</font></font>

If yes, please specify

Have you stopped certain medications or treatments? *

<font style="vertical-align: inherit;"><font style="vertical-align: inherit;">Yes</font></font>

<font style="vertical-align: inherit;"><font style="vertical-align: inherit;">No</font></font>

If yes, please specify

Please read the information below and check I accept the conditions. I understand that Nature Medic does not replace my family doctor and cannot guarantee the effectiveness of the treatment, nor be responsible for any side effects that may occur. I consent to Nature Medic disclosing my personal information to health professionals assigned to my file or to my attending physician. By becoming a patient at Nature Medic, I agree to receive their communication by email. I also understand that Nature Medic does not sell any product and cannot be held responsible for the quality or availability of medical cannabis products. I agree to follow the treatment plan that will be communicated to me, to obtain supplies from suppliers authorized by Health Canada and to notify the clinic if I stop taking treatment. I understand that I can move my appointment by giving 48 hours notice, but that any canceled or missed appointment will not be refunded.*

<font style="vertical-align: inherit;"><font style="vertical-align: inherit;">I accept </font></font>

<font style="vertical-align: inherit;"><font style="vertical-align: inherit;">I refuse</font></font>

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