Form C:

Delivery to Your Health Care Professional

Client Registration Form.

1 Applicant Information
Applicant's Name:
Date of Birth:
Gender:
Address:
 
Email Address*:
Mailing Address:
(if different from residence)
 
 
 

2 Individual(s) Responsible for the Applicant
(If you have caregiver(s), please complete this section)
Person 1 Name:
Date of Birth:
Gender:
Email Address*:
Person 2 Name:
Date of Birth:
Gender:
Email Address*:

3 Health Care Practitioner Information
(Required if shipping product to the Healthcare Practitioner)
Name:
Title/Profession:
Clinic Business Name:
Licence:
Address Line 1:
 
 
 
 

* Have your Healthcare Practitioner complete this section if they have agreed to receive medical marihuana on your behalf. Product will ship to the business address specified on the Medical Document. Withdrawal of consent by the Health Care Practitioner: If the Health Care Practitioner ceases to consent to receive dried marijuana for the applicant, the practitioner must send a written notice to that effect to the client and to the Licensed Producer.


4 Additional Information
(optional)
Is there anything else you would like us to know?

5 Acknowledgement
 

The Applicant and/or the 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.

Applicant / Individual Responsible Signature:
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.

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