Prescribers use this seven-page form for a worker's first request for WCB Nova Scotia coverage of medical cannabis. It documents the diagnosis and objective findings, prior pharmaceutical trials including a synthetic cannabinoid, a risk assessment, current medications and substance use, a cannabis treatment agreement, baseline function and pain, measurable goals, and the proposed product and THC dose. Requests are judged against WCB's medical cannabis criteria.
The prescriber completes the whole form after an in-person physical exam and must agree to manage and monitor the condition being treated. If they are not the primary treating health professional, that professional must be aware of and support the treatment.
Download the current version from the source each time; forms change without notice.
INITIAL REQUEST FORM for Medical Cannabis
Upload the fillable PDF once and Vero Documents fills it from the visit note and the chart, ready for you to review and sign. Download, print, or email the finished form, with the patient’s consent.
A form is listed only after its name and number were confirmed on the issuing agency’s or insurer’s own website, or in the form itself. Each entry links to that source. The list was last checked in October 2026. Forms change without notice, so download the current version from the official page before you fill it in.
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An eligible condition related to the compensable injury, conventional treatments exhausted over at least 12 weeks including a synthetic cannabinoid, no listed contraindications, expected benefits that outweigh the risks, a comprehensive assessment with measurable goals, and a signed treatment agreement. The authorizer must also take responsibility for ongoing monitoring and reassessment.
The authorizer, who must be responsible for managing the ongoing care of the condition and for regular reassessments. If you are not the primary treating health professional, the form asks whether that professional knows about and supports the treatment, and requests are not evaluated unless you agree to monitor the condition.
For refractory neuropathic pain, a table of first-line agents (TCAs, SNRIs, gabapentinoids), second-line agents (tramadol or opioids) and third-line synthetic cannabinoids, with start dates, maximum dose reached, beneficial and adverse effects, and the reason and date for stopping. If fewer than three categories were tried, explain why.