Registration & Consent to Disclose
Full Name
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First Name
Last Name
Email
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example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
VAC Number
Referral Code
Date of Birth
-
Year
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Month
Day
4 digit year, 2 digit month, 2 digit day
Date
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I authorize Base Wellness to disclose to Veterans Affairs Canada.
*
Yes
No
Who is completing this form?
I am completing this form for myself
I am an individual responsible for the applicant for the person obtaining medical cannabis
Applicant Full Name
*
First Name
Last Name
Personal Information Permitted to Disclose
My personal health information consisting of dose information of cannabis used for medical purposes, the specific condition for which medical cannabis is being used, and any additional information required to validate my eligibility for coverage.
Information Permitted to Disclose
The personal health information of the applicant consisting of dose information of cannabis used for medical purposes, the specific condition for which medical cannabis is being used, and any additional information required to validate my eligibility for coverage.
Confirmation
I represent and warrant that I meet all of the requirements to be the applicant’s substitute decision-maker under the applicable legislation.
I understand the purpose of disclosing this personal health information to Veterans Affairs Canada.
I understand that I can refuse to sign this consent form.
Confirm Form is Complete
Yes
Signature
Please verify that you are human
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BOS JotForm Submission Key
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