Patient Registration Without Residence

Step 1 of 4

Applicant Information

Full Name *

First

Last

Date of Birth *//

MM/DD/YYYY

Gender *

Identifies as (optional)

Phone Number *

Fax Number

Email Address *

No Email Address

I don't have an email address

Is this registration for interim supply? *

Caregiver / Individual Responsible for Applicant

Complete this section only if there is caregiver or individual responsible for the applicant.

Caregiver

I do not have a caregiver or individual responsible for me

Caregiver Name *

First

Last

Caregiver Date of Birth *//

MM/DD/YYYY

Gender *

Phone *

Caregiver / Person Responsible Declaration *

By signing, I declare responsibility for the Applicant.

Date *//

MM/DD/YYYY

Other Individual(s) Responsible for the Applicant

Do you have more than one caregiver?

I have more than one caregiver

Health Care Practitioner Information

Complete only if your health practitioner is consenting to receive dried marijuana and/or cannabis oil on your behalf.

Send marijuana to practitioner

Send dried marijuana and/or cannabis oil to my practitioner

IMPORTANT - Please read and sign below

The undersigned applicant or person responsible hereby agrees and warrants that:

The undersigned applicant or person responsible hereby agrees and warrants that: 1) Applicant ordinarily resides in Canada. 2) The original Medical Document accompanies this Application. 3) The applicant understands and acknowledges that any Medical Documents sent with this form cannot be returned once registration is complete. 4) The medical document/registration certificate is not being used to seek or obtain fresh or dried marijuana and/or cannabis oil from another source. 5) The information in the original application and medical document/registration certificate is correct and complete. 6) The Applicant will use fresh or dried marijuana and/or cannabis oil only for his or her own medical purposes. 7) The Applicant understands and acknowledges that medicinal marijuana is not currently approved for use as a drug in Canada and that its safety and risks have not been fully studied and the appropriate dosage is unclear. 8) The Applicant acknowledges and agrees that he or she is using any medicinal marijuana product obtained by Redecan at his or her own risk, and releases Redecan (and its partners, providers, officers, directors and staff) from any and all actions, claims, complaints and demands for damages, loss of injury whatsoever arising directly or indirectly from the use of medicinal marijuana obtained from Redecan. 9) The Applicant consents to the health care practitioner named in this document disclosing required personal health information to Redecan for the purposes of complying with the requirements of the Access to Cannabis for Medical Purposes Regulations (ACMPR). The Applicant understands and agrees that a copy of this consent & registration application may be provided to the health care practitioner named herein. *

I agree *

• Applicant ordinarily resides in Canada

• The original Medical Document accompanies this Application.

• The applicant understands and acknowledges that any Medical Documents sent with this form cannot be returned once registration is complete.

• The medical document/registration certificate is not being used to seek or obtain fresh or dried marijuana and/or cannabis oil from another source.

• The information in the original application and medical document/registration certificate is correct and complete

• The Applicant will use fresh or dried marijuana and/or cannabis oil only for his or her own medical purposes

• The Applicant understands and acknowledges that medicinal marijuana is not currently approved for use as a drug in Canada and that its safety and risks have not been fully studied and the appropriate dosage is unclear.

• The Applicant acknowledges and agrees that he or she is using any medicinal marijuana product obtained by Redecan at his or her own risk, and releases Redecan (and its partners, providers, officers, directors and staff) from any and all actions, claims, complaints and demands for damages, loss of injury whatsoever arising directly or indirectly from the use of medicinal marijuana obtained from Redecan.

• The Applicant consents to the health care practitioner named in this document disclosing required personal health information to Redecan for the purposes of complying with the requirements of the Access to Cannabis for Medical Purposes Regulations (ACMPR). The Applicant understands and agrees that a copy of this consent & registration application may be provided to the health care practitioner named herein.

Applicant / Individual Responsible Signature *

Date *//

MM/DD/YYYY

Name

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