Form A: Applicants with a Residence

Client Registration Form

1. Applicant Information

2. Individual(s) Responsible for the Applicant

If you have caregiver(s), please complete this section

Person 1:


Person 2:


3. Healthcare Practitioner Information

4. Additional Information


5. Acknowledgement

The Applicant and/or person responsible for the applicant must read and acknowledge the following:

  • The applicant is ordinarily a resident of Canada.
  • The information in the application and medical document is
    correct and complete.
  • The medical document is not being used to seek or obtain
    fresh or dried marihuana, or cannabis oil from another source.
  • The original medical document accompanies this application.
  • The applicant will use fresh or dried marihuana or cannabis oil
    only for their own medical purposes.

Important note: When returning this application please include the original medical document signed & dated by your health care practitioner. The original copy of the medical document is required to complete your registration.

Herbal Cannabis

One of the more popular consumption options is to grind the cannabis bud and smoke it either in a device (like a pipe) or to use rolling papers to roll it into a marijuana cigarette (joint). If you wish to directly consume the cannabis bud but don’t wish to smoke, you can always use a Vaporizer – which is part of Beleave’s harm reduction program.