ACKNOWLEDGMENT OF APPLICANT
VETERANS AFFAIRS COVERAGE
SIGNATURE* DATE (MM/DD/YEAR)*
• The applicant acknowledges that some of the information provided
in this document may be shared with Health Canada, our service
providers, Veterans Aairs, 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?
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.
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
Thank you for registering with Broken Coast