Patient Registration Without Residence Please enable JavaScript in your browser to complete this form. - Step 1 of 4Applicant InformationFull Name *FirstLastDate of Birth *MM123456789101112/DD12345678910111213141516171819202122232425262728293031/YYYY20232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920MM/DD/YYYYGender *Please choose oneMaleFemaleOtherIdentifies as (optional)Please choose oneMaleFemaleOtherPhone Number *Fax NumberEmail Address *No Email AddressI don't have an email addressIs this registration for interim supply? *Please choose oneNoYesNextEstablishment InformationThe facility where you currently resideEstablishment Name *Establishment Type *Please choose onePrivate homeNursing homeShelterHostelOtherOther Type *Please specify other type of residenceManager's Name *FirstLastEstablishment Office Address *Address Line 1Address Line 2CityAlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNova ScotiaNorthwest TerritoriesNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukonProvincePostal CodePhone Number *Fax NumberEmail *Manager's Signature *Clear SignatureI attest that the establishment provides food, lodging and other services to the Applicant.Date *MM123456789101112/DD12345678910111213141516171819202122232425262728293031/YYYY20232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920MM/DD/YYYYMailing AddressWhere you receive correspondence - Complete if different from 'Establishment Office Address' listed aboveMailing AddressSame as Establishment AddressMailing Address *Address Line 1Address Line 2CityAlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNova ScotiaNorthwest TerritoriesNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukonProvinceShipping AddressWhere you want product shipped.Shipping AddressSame as Mailing AddressShipping Address *Address Line 1Address Line 2CityAlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNova ScotiaNorthwest TerritoriesNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukonProvincePostal CodePreviousNextCaregiver / Individual Responsible for ApplicantComplete this section only if there is caregiver or individual responsible for the applicant.CaregiverI do not have a caregiver or individual responsible for meCaregiver Name *FirstLastCaregiver Date of Birth *MM123456789101112/DD12345678910111213141516171819202122232425262728293031/YYYY20232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920MM/DD/YYYYGender *Please choose oneMaleFemalePhone *Caregiver / Person Responsible Declaration *Clear SignatureBy signing, I declare responsibility for the Applicant.Date *MM123456789101112/DD12345678910111213141516171819202122232425262728293031/YYYY20232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920MM/DD/YYYYOther Individual(s) Responsible for the ApplicantDo you have more than one caregiver?I have more than one caregiverCaregiver Name *FirstLastCaregiver Date of Birth *MM123456789101112/DD12345678910111213141516171819202122232425262728293031/YYYY20232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920MM/DD/YYYYGender *Please choose oneMaleFemalePhone *Caregiver / Person Responsible's Signature *Clear SignatureI declare that I am responsible for the Applicant.Date *MM123456789101112/DD12345678910111213141516171819202122232425262728293031/YYYY20232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920MM/DD/YYYYHealth Care Practitioner InformationComplete only if your health practitioner is consenting to receive dried marijuana and/or cannabis oil on your behalf.Send marijuana to practitionerSend dried marijuana and/or cannabis oil to my practitionerPractitioner Title *Practitioner Name *FirstLastPractitioner Phone Number *Practitioner Fax NumberEmail *Clinic Name *Office Address *Address Line 1Address Line 2CityAlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNova ScotiaNorthwest TerritoriesNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukonProvincePostal CodeConsent to receive dried marijuana and/or cannabis oil on behalf of applicant *Ship dried marijuana and/or cannabis oil to my officeHealth Care Practitioner's Signature *Clear SignatureI consent to receive marijuana and/or oil on behalf of the Applicant.Date *MM123456789101112/DD12345678910111213141516171819202122232425262728293031/YYYY20232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920MM/DD/YYYYPreviousNext*IMPORTANT* - Please read and sign belowThe 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 *Clear SignatureDate *MM123456789101112/DD12345678910111213141516171819202122232425262728293031/YYYY20232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920MM/DD/YYYYPreviousWebsiteSubmit