Renewal Form

Registration Renewal Form

Required fields are marked with*.

Contact Information

First Name

Last Name

Title

Middle Name

Preferred Name

Gender

Date of birth

If you change the information in above section, you must separately submit supporting documentation (eg. Driver's License, Health Card, Passport, Legal Name Change Certificate, Marriage Certificate, etc.)

Contact Information

Email *

Phone #1 *

Phone #2

Phone #3

Primary Address

Address Line 1 *

Address Line 2 *

City *

Province *

Postal Code*

This is non-private residence (ex. Nursing home, group home)

Mailing Address

Use my primary address

Address Line 1 *

Address Line 2

City *

Province *

Postal Code *

Shipping Address

My Primary Address My Mailing Address My Physician

Note: If you select my physician, you must also provide a singed statement of consent to receive dried or fresh cannabis or cannabis oil form your prescribing your physician before making this selection.

Representations

AGREEMENT*

By clicking this checkbox, I represent that the above statements are true.

Consents

Your personal data and personal health information (collectively, "Information") will be used by us and our third-party vendors to support your experience throughout this transaction, including to process payment, shipment, purchases, communications with you regarding your account and purchases, and for other purposes described in the software vendor's privacy policy. You may also contact your Health Care Practitioner to learn how the Health Care Practitioner may use Information provided by you on this platform.

DISCLOSURE OF PERSONAL HEALTH INFORMATION*

I consent to the disclosure of my Information to the Health Care Practitioner named in the Medical Document Authorizing the Use of Cannabis for Medical Purposes ("Medical Document") and the Medical Cannabis Provider as required by applicable law. I understand and agree that my Information may be shared on a confidential basis with service providers when required for the provision of the service.
I understand that my Information may be shared with provincial/territorial health care licensing authorities responsible for regulating the professional practices of health care practitioners. I also understand that my Information may be shared with law enforcement when required by law, including when necessary to confirm that I am lawfully allowed to possess a limited amount of cannabis for medical purposes. Further, I understand that my Information may be disclosed in limited and specific situations without my consent in accordance with applicable law.

DELIVERY TO HEALTH CARE PRACTITIONER*

I consent to a copy of this document being provided to the Health Care Practitioner named in the Medical Document.

THIRD-PARTY SERVICES*

I consent to trans-border data flow that may happen when certain third-party services are used to support services, including shipping services and email communications. The information that may be shared with trans-border service providers is limited to your name, mailing address, and email address. We do not sell or share health information with third parties. Any trans-border data transfer carries some risk that the confidentiality of the data could be affected. However, we follow all industry-standard data transfer best practices and transfer data in compliance with applicable laws.

YOUR RIGHTS

To revoke your consent for any of the above items, please contact your Health Care Practitioner or the Medical Cannabis Provider directly. You have the right to request access to your Information, and to request a correction of your Information. You can exercise your rights under this consent form by contacting your Medical Cannabis Provider. You can also learn more about how to exercise rights under your Medical Cannabis Provider or Health Care Practitioner's policy by visiting the website of your Medical Cannabis Provider or Health Care Practitioner.

DIGITAL SIGNATURE*

Please type your first and last name here. This will serve as your digital signature

Concentrates

Accessories

Edibles

Dried Flower

Extracts

Medical

Beverages

Pre-Rolls

Topicals

Vapes

Registration Renewal Form

Contact Information

Contact Information

Primary Address

Mailing Address

Shipping Address

Representations

Consents

Are you 19 years of age or older?