Register - My Canna Clinic

Referrer*

Name*

First Last

Username*

Email*

Password*

Enter Password Confirm Password

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Date of Birth*

DD

MM

YYYY

What is your biological sex?*

For medical reasons, in order to provide appropriate treatment, it is important to answer scientifically.

What do you identify your gender as?*

Do you have a preferred gender pronoun?*

Yes
No

What is your preferred gender pronoun?*

Phone Number*

Why are you applying for medical cannabis?

Health Card Number*

Are you an existing patient?*

Yes
No

Previous Clinic

Patient ID

Are you needing your medical file transferred over from an existing clinic?*

Yes
No

I consent to International Medical Consulting requesting my medical records from my previous medical clinic.

Previous Licensed Producer

Are you a veteran?*

Yes
No

K Number

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Is your shipping address different from your primary address?*

Yes
No

Shipping Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Are you the Applicant's Caregiver?*

Yes
No

Care Giver's Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Care Giver's First Name

Care Giver's Surname

Care Giver's Date of Birth

Care Giver's Email Address

Care Giver's Phone Number

Care Giver's Signature

Is this a private address?*

Yes
No

Residence Type*

Healthcare Practitioner
Nursing/Care Home
Social Services Establishments

Name of Establishment

Relationship to Applicant

First Name of Person Receiving

Last Name of Person Receiving

Title

Email

Phone Number

Certification By*

Healthcare Practitioner
Nursing/Care Home
Social Services Establishments

Residence Signature

I hereby certify that I or the institution by or with which I am affiliated or employed is providing services to the Applicant. I hereby consent to receive cannabis on behalf of the Applicant listed above. I hereby certify that I am responsible for the Applicant named above. Note: If at any time you wish to withdraw consent to receive cannabis on behalf of the Applicant, you must provide written notice to that effect to both the Applicant and the Licensed Producer.

Applicant Declaration

The following declaration should be signed either by the Applicant or the person responsible for the Applicant: I hereby certify that the Applicant named herein is normally a resident in Canada. I and/or the Applicant have read the “General Terms and Conditions” as published on the web site included in the “International Medical Consulting” (as therein defined) which I agree to incorporate into this document by reference, and to which I acknowledge that I am bound. I further certify that information given in this application and in any appended documents (i.e. proof of legal name change) is both correct and complete.

Patient's Signature*

I hereby consent to receive cannabis on behalf of the Applicant listed above. I hereby certify that I am responsible for the Applicant named above. Note: If at any time you wish to withdraw consent to receive cannabis on behalf of the Applicant, you must provide written notice to that effect to both the Applicant and the Licensed Producer.