RegisterPatient Registration1. Patient Registration2. DoneWelcome! Please specify whether you are a patient or caregiver, then fill out the form below to register. * I am a patient I am a caregiver Caregiver Information First Name * Middle Name * Last Name * DOB * Gender * Male Female Mobile Number* Email * Caregiver Residing Address Address 1 * Address 2 (Apt, Ste #) City * Province * AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Postal Code * Do you reside at the same address as the patient? * Yes No Do you have a referral code * Yes No Enter Referral Code * Patient Information First Name * Middle Name Last Name * DOB * Gender * Male Female Phone Number * Email * K Number (Veterans Only) Residing Address Address 1 * Address 2 (Apt, Ste #) City * Province * AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Postal Code * Shipping Address Is your shipping address the same as your residing address? * Yes Patient Residing Address No Shipping Address Address 1 * Address 2 (Apt, Ste #) City * Province * AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Postal Code * Is this shipping address a private residence? * Yes No Establishment Name * Declaration of the Applicant or the Person Responsible for the ApplicantImportant – please read and sign below:•The Applicant acknowledges that medical cannabis is not approved for the use as a drug in Canada, that its indications, safety and risks have not been adequately studied and the appropriate dosage is unclear.•The Applicant acknowledges and agrees that he or she is using any medical cannabis product obtained from Optimus Cannabis, Inc. at his or her own risk, and releases Optimus Cannabis Inc. (and its production partners) from any and all actions, claims, complaints and demands for damages, loss or injury whatsoever arising directly or indirectly as a consequence of the use of medical cannabis obtained from Optimus Cannabis, Inc.•The Applicant is ordinarily a resident in Canada.•The information in the application and Medical Document is correct and complete.•The original Medical Document is provided in support of this application or has/will be sent separately.•The Medical Document is not being used to seek or obtain fresh or dried cannabis, or cannabis extracts from another source.•The Applicant will use fresh or dried cannabis, or cannabis extracts, only for their own medical purposes.•The Applicant gives consent to Optimus Cannabis, Inc. to forward the necessary personal information to our production licensed producer, the applicant’s health care practitioner, and service providers for purchasing, shipping, verification and distribution purposes only.•The Applicant gives consent to his or her health care practitioner to forward the necessary personal information to Optimus Cannabis, Inc. in order to register the Applicant and fulfill his or her orders.•The Applicant may revoke the consent given at any time by providing written notice to Optimus Cannabis, Inc.Signature Date Submit All SetMail to Submit your Medical Document Fax your Medical Document to: Download Form Continue Browsing
