London Cannabis Compassion Center Lynn Harichy 199 Wellington St. London, ON N6B 2K9 519-474-3943

Application for Category Two (Please print) Dear Physician, L.C.C.C. is a non-profit resource center established for the benefit of people suffering from incurable condtions such as HIV, AIDS, cancer, multiple sclerosis, muscular dystrophy, glaucoma, epilepsy, fibromyalgia, arthritis, insomnia, anorexia, intractable pain, paraplegia and quadraplegia. Your patient is requesting a letter of diagnosis from you on your behalf. The purpose of the letter is simply to document, for our records, that this person has been diagnosed with a serious ailment and that their doctor feels that cannabis may have therapeutic value for them. We have provided a sample letter for you to use as a guide. Please keep a copy of this letter and the accompanying Release of Confidential Medical Information in your patient's file as someone from L.C.C.C. will call to quickly verify the validity of the letter.

Sample Letter Date: Dear L.C.C.C. This letter is to certify that ____________________ has been diagnosed with ______________________________ and that I as (patient's) Physician feel that cannabis may be beneficial to him/her. I am a licensed physician permitted to practice medicine and write prescriptions in the province of Ontario. I understand that myself or my office will be contacted by telephone to verify this information. Yours Sincerely, ______________________________ (physician's original signature)

Thank you for your time and best regards, The staff of L.C.C.C. Category Specifications  |  Category One Form  |  Category Two Form  |  Home  |  mharichy@worlddrive.com