Complete this form to register as a customer for the purchase of medical cannabis.
Please send BOTH pages to us.
A.Complete Registration Form
To register as a customer for the purchase of medical cannabis, complete and sign this Registration Form and send it to us by one of the following:
1.Secure ePortal fax line
ATTN: Patient Care TeamUnit# A09A 6120-2 Street SECalgary, AB, Canada T2H 2L8
Your healthcare professional can also send us your Registration Form by secure fax along with your Medical Document.
B.Complete a Medical Document with your Healthcare Professional
We will also need the original version of your Medical Document, completed by your healthcare professional. We can accept this document by fax only directly from your healthcare professional’s office. Otherwise, you or your doctor will need to mail us the original paper version. If you need assistance with this, we’ll be pleased to arrange for the collection of your forms and/or to provide you with a self-addressed, prepaid envelope uponrequest.
Once we receive your Registration Form and Medical Document, we will verify the documents. We will send you a confirmation email, at which point you can place your first order.
To reach our Patient Care Team, and/or for help filling out this registration form, contact us by telephone at 1-888-585-8890 or by email at email@example.com.
*Direct billing is subject to approval by Veterans Affairs Canada.