I declare the following to be true:
- I am at least 19 years of age
- I am aware marijuana is not an approved therapeutic agent in Canada
- I wish to consider the use of marijuana as medicine despite potential side effects
- I have a medical condition (diagnosis) that may benefit from marijuana
- I am legally able to make all of my health decisions on my own
- I agree not to make any claim or commence any proceedings against heads.ca / family physicians / or any other involved physicians in relation to my use of marijuana (ganja / cannabinoids)
- I do not support any claims made by my family, friends or other interested parties against said heads.ca and physicians. I release Headz.ca / my family physician / any other involved physicians from any and all actions, claims, causes of actions, complaints (even by family and friends) and demands for damages, loss, or injury whatsoever arising directly or indirectly as a consequence to my use of marijuana (ganja / cannabinoids). This release from liability is to be binding on heirs, executors and assigns.
SIDE EFFECTS CONSENT (I declare the following to be true)
- I acknowledge there has only been limited research into the safety of marijuana and that the safety and efficiency of dried marijuana for medical purposes has not been established. No notice of compliance has been issued for marijuana in Canada. I understand and accept the following possible consequences of marijuana use including but not limited to: impaired judgment, anxiety, paranoia, sedation, decreased inhibitions, drug tolerance, possible dependence, possible withdrawal symptoms, the need for possible drug holidays, an increase in appetite leading possibly to weight gain, an impaired immune system, interaction with other drugs, the possible need to decrease the dose of some medications (with the supervision of my primary care physician), dysphoria (an unpleasant emotional state), depleted energy, impaired short term memory, and lung damage (smoked form)
- I acknowledge that all of the potential health risks associated with marijuana may not yet have been identified and that marijuana may have an adverse effect on my health in the future
- I acknowledge the use of marijuana may have an effect on my motor skills. Consequently I will not operate a motor vehicle, handle machinery or perform other risky activities if impaired with marijuana
- I understand that the use of marijuana may be dangerous during pregnancy. I agree to notify my primary care practitioner if I have any significant side effects arising from my use of marijuana.
Statement of Conscience or Religious Belief
Possession of ganja for religious purposes as a sacrament in adherence to the Rastafarian faith.
Make oath or solemnly affirm and say as follows:
The requirements of the Controlled Drugs and Substances Act conflict with my sincerely held convictions based on my religion or conscience.
I understand that the Governor General Sir Patrick Allen of Jamaica a Commonwealth member has granted royal assent decriminalizing Cannabis for religious purposes as a sacrament in adherence to the Rastafarian faith and that The Canadian Charter of Rights and Freedoms guarantees the rights and freedoms set out in it subject only to such reasonable limits prescribed by law as can be demonstrably justified in a free and democratic society.
Everyone has the following fundamental freedoms: (a) freedom of conscience and religion;