Step 1 of 3 33% Patient Name* First Last What is The Best Time To Contact You?* Morning Afternoon Evening How Do You Prefer to Communicate?* Email Telephone Both Your Contact Information* Street Address Address Line 2 City AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code* Email* Enter Email Confirm Email Your Phone*Mobile #Date of Birth*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year20232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Age*In YearsPlease enter a number from 19 to 100.Sorry... We cannot complete your application. Canadian regulations require that all applicants are 19 years old or older. Gender* Male Female Weight (lbs.)* Marital Status* Single Married Divorced Widowed Do you smoke cigarettes?* Yes No Occupation* Employment Status* Full Time Part Time Unemployed Retired Do you drink alcohol?* Yes No How many drinks per week?* Health Card No.* Confirm Health Card No.* Province (Health Card)*AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland & LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukonExpiry Date* MM slash DD slash YYYY Expiry Date MM slash DD slash YYYY Patient Signature*Date Signed MM slash DD slash YYYY Licensed Producer(s)* Current Dose Per Day* Are you asking to increase your dosage?* Yes No If Yes Proposed Daily Dose* What form do you most often use?* Edible Vaporizer Smoking Strain (% THC % CBD)* Do You Experience any Side Effects?* Yes No If Yes Please DescribeSince taking cannabis is your condition:* Better Same Worse Why are you taking Cannabis?* Pain Anxiety/Depression Seizures Other If Other Please Describe IDENTITY SECTION 4 WAYS TO UPLOAD 1. Picture (Smartphone) 2. Scan From Home or Office Depot or Copy Store 3. Scan with Mobile App (Android OR iPhone) [<< Download Free App] 4. Upload PDF, JPEG, JPG OR PNG Files Upload Your Identification DocumentsPhoto Health Card Drop files here or Select files Accepted file types: jpeg, jpg, png, pdf, Max. file size: 2 MB, Max. files: 1. You can upload one file hereFinancial Documents (If Applicable) Drop files here or Select files Accepted file types: jpeg, jpg, png, pdf, Max. file size: 2 MB, Max. files: 1. You can upload financial document here.Licensed Producers*Spectrum (Tweed)Weed MDAphriaOrganigramMedReleafBroken CoastCannafarmsOtherPlease choose one.Other* Other Licensed Producer NameUpload Other application form hereAccepted file types: pdf, jpg, png, Max. file size: 2 MB.Click the following link to Submit the Spectrum Cannabis digital form: Spectrum Cannabis Digital Or download the form by clicking this link to the PDF version and upload once it is filled. Spectrum Cannabis PDF To save this form and return to complete later click the Save and Continue Later link bottom of this page.Upload Spectrum Cannabis HereAccepted file types: pdf, jpg, png, Max. file size: 2 MB.Click the following link to Submit the Weed MD digital form: Weed MD Digital Or download the form by clicking this link to the PDF version and upload once it is filled. Weed MD PDF To save this form and return to complete later click the Save and Continue Later link bottom of this page.Upload Weed MD HereAccepted file types: pdf, jpg, png, Max. file size: 2 MB.Click the following link to Submit the Aphria digital form: Aphria Digital Or download the form by clicking this link to the PDF version and upload once it is filled. Aphria PDF To save this form and return to complete later click the Save and Continue Later link bottom of this page.Upload Aphria HereAccepted file types: pdf, jpg, png, Max. file size: 2 MB.Click the following link to Submit the Organigram digital form: Organigram Digital Or download the form by clicking this link to the PDF version and upload once it is filled. Organigram PDF To save this form and return to complete later click the Save and Continue Later link bottom of this page.Upload Organigram HereAccepted file types: pdf, jpg, png, Max. file size: 2 MB.Click the following link to Submit the MedReleaf digital form: MedReleaf Digital Or download the form by clicking this link to the PDF version and upload once it is filled. MedReleaf PDF To save this form and return to complete later click the Save and Continue Later link bottom of this page. Upload MedReleaf HereAccepted file types: pdf, jpg, png, Max. file size: 2 MB.Click the following link to Submit the Broken Coast digital form: Broken Coast Digital Or download the form by clicking this link to the PDF version and upload once it is filled. Broken Coast PDF To save this form and return to complete later click the Save and Continue Later link bottom of this page.Upload Broken Coast HereAccepted file types: pdf, jpg, png, Max. file size: 2 MB.Click the following link to Submit the Cannafarms digital form: Cannafarms Digital Or download the form by clicking this link to the PDF version and upload once it is filled. Cannafarms PDF To save this form and return to complete later click the Save and Continue Later link bottom of this page.Upload Cannafarms HereAccepted file types: pdf, jpg, png, Max. file size: 2 MB.Please check this box if you have uploaded/submitted the License Producer's form.* I have Submitted/Uploaded the License Producer form. Please check this box if you have uploaded/submitted the License Producer's form.Signature*Date Signed* MM slash DD slash YYYY PhoneThis field is for validation purposes and should be left unchanged.
