Fillable Rede Can Pharm Patient Registration With Residence 2018

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Rede Can Pharm Patient Registration With Residence 2018

On average this form takes 21 minutes to complete

The Rede Can Pharm Patient Registration With Residence 2018 form is 3 pages long and contains:

  • 4 signatures
  • 19 check-boxes
  • 61 other fields

Country of origin: CANADA
File type: PDF

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Registration Application
Complete if you have a permanent
residence
Male
Female
Surname (Last Name)
Full Name:
APPLICANT INFORMATION
Given First Name(s)
Fax Number
Contact:
Phone Number
Email Address
Name of Establishment (if not a private residence)
If Other, Please Specify
Date of Birth:
Day / Month / Year
Gender:
Street Address 1
Street Address 2 (If Applicable)
Residence
Type:
Unit #
CONTACT INFORMATION - Primary Residence (Must be in Canada and cannot be post office box).
Primary
Residence:
MAILING ADDRESS
Street Address 1
Street Address 2 (if applicable)
Mailing
Address:
Unit #
Same as primary residence above
Where you receive correspondence. Complete if your mailing address is different than your primary residential address.
City Province Postal Code
Street Address 1
Street Address 2 (If Applicable)
Unit #
City Province Postal Code
City Province Postal Code
Private home Nursing home Shelter Hostel Group Home Other
Same as primary residence above (where you want product shipped).
Must be a residence.
Mailing
Address:
redecan.ca | Registration application for patients with residence
Page 1 of 3
Is this registration for interim supply?
No
Yes
Send completed documents to:
Mail
Redecan P.O. Box 138
Ridgeville, Ontario, L0S 1M0
E-Mail
info@redecan.ca
Fax
1-905-892-6711
Male
Female
Identifies as:
Other
(optional)
Registration Application
Complete if you have a permanenet
residence
Male
Female
Surname (Last Name)
Caregiver
Name:
CAREGIVER / INDIVIDUAL RESPONSIBLE FOR APPLICANT
Caregiver Phone Number
Given First Name(s)
Caregiver
Date of Birth:
Day / Month / Year
Gender:
I
am responsible for
Caregiver / Person Responsible Full Name Applicant’s Full Name
/ /
Caregiver
Signature:
DATE: Day Month Year
Male
Female
Surname (Last Name)
Caregiver
Name:
OTHER INDIVIDUAL(S) RESPONSIBLE FOR THE APPLICANT - (IF YOU HAVE MORE
THAN ONE CAREGIVER)
Caregiver Phone Number
Given First Name(s)
Caregiver
Date of Birth:
Day / Month / Year
Gender:
/ /
Caregiver
Signature:
DATE: Day Month Year
redecan.ca | Registration application for patients with residence
Page 2 of 3
Caregiver / Person Responsible Declaration:
I
am responsible for
Caregiver / Person Responsible Full Name Applicant’s Full Name
Caregiver / Person Responsible Declaration:
Send completed documents to:
Mail
Redecan P.O. Box 138
Ridgeville, Ontario, L0S 1M0
E-Mail
info@redecan.ca
Fax
1-905-892-6711
click to sign
signature
click to edit
click to sign
signature
click to edit
Registration Application
Complete if you have a permanenet
residence
Given First Name(s)
Surname (Last Name)
Title
Contact:
Clinic Name:
Practitioner Phone Number Practitioner Fax Number Practitioner Email
Street Address 1
Street Address 2 (If Applicable)
Primary
Residence:
Unit #
City Province Postal Code
Ship dried marihuana
and/or cannabis oil to
my office
Send dried marihuana and/or cannabis oil
to the shipping address above
/ /
Health Care
Practitioner’s
Signature:
DATE: Day Month Year
Consent to receive dried marihuana
and/or cannabis oil on behalf of
applicant
I
consent to receive marihuana and/or cannabis oil on behalf of
Name of Health Care Practitioner Applicant’s Full Name
*IMPORTANT* - PLEASE READ AND SIGN BELOW
The undersigned applicant or person
responsible hereby agrees and warrants that:
• Applicant ordinarily resides in Canada.
• The original Medical Document accompanies this Application.
• The applicant understands and acknowledges that any Medical Documents sent with this form cannot be returned once registration is
complete.
• The medical document/registration certificate is not being used to seek or obtain fresh or dried marijuana and/or cannabis oil from
another source.
• The information in the original application and medical document/registration certificate is correct and complete.
• The Applicant will use fresh or dried marihuana and/or cannabis oil only for his or her own medical purposes.
• The Applicant understands and acknowledges that medicinal marihuana is not currently approved for use as a drug in Canada and
that its safety and risks have not been fully studied and the appropriate dosage is unclear.
• The Applicant acknowledges and agrees that he or she is using any medicinal marihuana product obtained from Redecan at his or her
own risk, and releases Redecan (and its partners, providers, officers, directors and staff) from any and all actions, claims, complaints
and demands for damages, loss or injury whatsoever arising directly or indirectly from the use of medicinal marihuana obtained from
Redecan.
• The Applicant consents to the health care practitioner named in this document disclosing required personal health information to
Redecan for the purposes of complying with the requirements of the Access to Cannabis for Medical Purposes Regulations
(ACMPR). The Applicant understands and agrees that a copy of this consent & registration application may be provided to the health
care practitioner named herein.
redecan.ca | Registration application for patients with residence
Page 3 of 3
/ /
Applicant/Individual
Responsible Signature:
DATE: Day Month Year
HEALTH CARE PRACTITIONER INFORMATION
Complete only if your health care practitioner is consenting to receive dried marihuana and/or cannabis oil on your behalf.
Name:
Send completed documents to:
Mail
Redecan P.O. Box 138
Ridgeville, Ontario, L0S 1M0
E-Mail
info@redecan.ca
Fax
1-905-892-6711
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signature
click to edit
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signature
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Rede Can Pharm Patient Registration With Residence 2018

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Completed 18 July 2020

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