APPLICANT INFORMATION All fields marked with * are mandatory.
MEDICAL CLIENT REGISTRATION
FOR APPLICANTS WITH A PERMANENT ADDRESS
RESIDENTIAL ADDRESS
OR
IS YOUR RESIDENTIAL ADDRESS DIFFERENT FROM YOUR SHIPPING ADDRESS?*
FIRST NAME*
ADDRESS*
ADDRESS
CITY*
CITY
NAME OF ESTABLISHMENT
PROVINCE*
PROVINCE POSTAL CODE
TYPE OF ESTABLISHMENT
If no, please provide the name and type of the establishment below (example: nursing or care home)
POSTAL CODE*
PHONE NUMBER
DATE OF BIRTH (MM/DD/YEAR)*
If no phone or email are provided, we will contact you via mail.
Must be a physical address; no post office boxes allowed.
LAST NAME*
EMAIL ADDRESS
GENDER*
IS THIS A PRIVATE RESIDENCE? *
MALE
YES
NO, PLEASE SHIP TO MY RESIDENTIAL ADDRESS ABOVE
(for home delivery)
YES, PLEASE MAIL TO THE MAILING ADDRESS BELOW
(for pickup at post office or mail depot - must be associated with
your residential address)
FEMALE
NO
X
IMPORTANT:
The personal information provided on this form must match the
information that appears on your Supporting Document.
Only fill out if you chose “no” above
Only fill out if you chose “yes” above
Only fill out if you chose “no” above
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ACKNOWLEDGMENT OF APPLICANT
VETERANS AFFAIRS COVERAGE
SIGNATURE* DATE (MM/DD/YEAR)*
K NUMBER
The applicant acknowledges that some of the information provided
in this document may be shared with Health Canada, our service
providers, Veterans Aairs, and/or insurance providers, as
applicable, solely for the purposes of providing service support.
The applicant gives Broken Coast permission to share their ordering
information with their prescribing physician and/or the clinic
through which they received their consultation
The applicant ordinarily resides in Canada.
The information in the application and the Supporting Document is
correct and complete.
The Supporting Document is not being used to seek or obtain dried
or fresh marijuana or cannabis oil from another source.
For applicants applying using a Registration Certificate: The
application is for the purpose of obtaining an interim supply of fresh
or dried marijuana or cannabis oil.
For applicants applying using a Medical Document: The original of
the Medical Document accompanies the application.
The applicant will use dried marijuana or cannabis oil only for their
own medical purposes.
ARE YOU ELIGIBLE THROUGH VETERANS AFFAIRS?
NO YES
If yes, please provide your k number. Must be 7 digits.
Supporting Document refers to either a signed Medical Document or a Registration Certificate issued by Health Canada.
PLEASE NOTE
Forms with missing or incomplete mandatory fields cannot be accepted as per ACMPR regulations.
Please contact us if you have any questions regarding this form.
BROKEN COAST CANNABIS
3695 DRINKWATER RD. DUNCAN,
BC V9L 0E9
INFO@BROKENCOAST.CA
TEL 1-888-486-7579
FAX 1-888-486-6384
Thank you for registering with Broken Coast
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