Client Information
Name of Client
*
Client First Name
Client Last Name
Client Date of Birth
*
-
Month
-
Day
Year
Client Email Address
*
Telephone Number
*
Please enter a valid phone number.
Are You:
*
Please Select
A New Client
Seeking a Renewal
Residential Address:
*
Street Address
Street Address Line 2
City
Province
Postal
Shipping Location
*
Please Select
To Residence Address
To Mailing Address
To Agripharm (6954 County Road 9, Stayner, ON, L0M 1S0)
To My Health Care Professional (only upon permission from healthcare professional)
Mailing Address (if Different from Residential Address):
Street Address
Street Address Line 2
City
Province
Postal
Responsible Adult Information
Only complete this section if you are an individual responsible for the applicant
Responsible Adult First Name
Responsible Adult Last Name
-
Month
-
Day
Year
Responsible Person Date of Birth
Relationship to Applicant
Responsible Person Telephone Number
Responsible Person Email
I ,
Name
agree I am responsible for
Client Name
Signature
Health Care Practitioner Information
Title
Health Care Practitioner First Name
Health Care Practitioner Last Name
License Number
Address
Fax Number
Telephone Number
Veterans Affairs Canada
Veterans Affairs Policy Number or K Number
By indicating your K Number or Policy Number, you give permission to Agripharm Corp. to share your details with Veterans Affairs Canada and/or Insurance Provider.
Name of Policy Provider
Application Based on a Registration Certificate
Only to be completed if you hold a Registration Certificate issued by Health Canada
Cannabis Products you are looking to obtain
Please Select
Cannabis Seeds
Cannabis Plants
Other Cannabis Products
Residential Address of the Designated Person
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Address of Production Site Specified on the Registration Certificate
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Registration Certificate
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Client Consent
By signing this document you state that you understand, agree, and consent to each of the following statement:
I ordinarily reside in Canada.
The information in this application and the accompanying Medical Document is correct and complete.
The Medical Document that forms the basis for this application has not, to the knowledge of the individual signing this consent has been altered.
The Medical Document or Registration Certificate being submitted is not being used to seek or obtain cannabis from another source.
Cannabis products supplied for medical purposes are for my consumption ONLY.
The original Medical Document is provided in support of the application.
Medical cannabis is not currently approed for use as a Pharmaceutical drug in Canada. If providing a copy of a registration certificate, the copy is an accurate reproduction of the original.
I will use cannabis products obtained from Agripharm Corp. at my own risk.
I hereby release Agripharm Corp. and its related entities from all actions, claims, complaints, demands for damages, personal losses, and/or injuries arising dirctly or indirectly from the use of medical cannabis obtained from Agripharm.
I understand that this consent is valid for the duration of approved Registration unless I withdraw my consent earlier by sending a written request by email to
members@purple.ca
or by mail to: Agripharm Corp. 6954 County Road 9, Stayner, ON, L0M1S0
In the case where a responsible adult who is named under Section 5 is signing the statement, they are responsible for the applicant.
Client/ Responsible Adult Name
*
First Name
Last Name
Date
*
-
Month
-
Day
Year
Client/ Responsible Adult Signature
*
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