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First Name*

Last Name*

Phone Number*

Birth Date*

E-mail Address*

Street Address

Town / City*

Province

Postcode / Zip

Password*

Confirm Password*

Referral

**Note: Your prescription expires in one year from the date of registration. You will be sent a notification to renew your prescription 60 days prior to your expiry.**

Health insurance number

Veteran Number (If Applicable)

Medical Prescription

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Role

PatientVeteran

I ordinarily reside in Canada.*

True

The information in this application is correct and complete.*

True

To my knowledge, the medical document has not been altered.*

True

The medical document is not being used to seek or obtain cannabis from another source.*

True

I will use cannabis supplied on this application only for my own medical purposes.*

True

Full legal name (Signature)*

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