Registration Form

Are you a new client, a renewing client or looking to change your address?
New ClientRenewing ClientChange of Address

Please indicate who is completing the registration form.
PatientCaregiverHealthcare Provider on behalf of patient

Have you consulted with a healthcare practitioner and received a medical document?
Yes, I have a valid medical document.No, I need a medical document.

Client first name

Client last name

Telephone #

Email

Date of Birth

Gender
MaleFemaleOtherPrefer not to say

Caregiver Information

Caregiver First Name

Caregiver Last Name

Caregiver Phone #

Caregiver Date of Birth

Gender
MaleFemaleOtherUndisclosed

Patient Address
Address 1 (Street # and Street name)

Address 2 (Unit # and buzzer code if required)

City

Province

Postal Code

K number (Veteran's only)

Do you hold native status?
NoYes

Is your shipping address the same as the address listed above?
YesNo

If you said No, please provide your shipping address below. If you said yes, please skip ahead.

Shipping Address 1 (Street #, P.O. Box, etc.)

Shipping Address 2 (Unit #, Buzzer code, etc.)

City

Province

Postal Code

Agreement

The undersigned Client and/or Responsible Individual hereby understands, agrees, and warrants that:

1. The Client ordinarily resides in Canada.
2. The Medical Document that accompanies this Application is ORIGINAL. If a Cannabis Regulations Registration Certificate accompanies this Application, it must be a clear and legible copy of the certificate issued by the Minister. An Authorization to Possess (ATP), Personal Use Production License (PUPL), or Designated Person Production License (DPPL) may not be used to register with a Cannabis Regulations Licensed Producer (LP), as all validity dates have now passed. Once registration is completed, no Medical Document may be returned to the Applicant for any reason.
3. Registration with a Cannabis Regulations Licensed Producer (LP), on the basis of a new medical document, does NOT give the Applicant a license to possess cannabis. It permits the Applicant to purchase cannabis directly from that Licensed Producer for the duration outlined by the Health Care Practitioner (HCP) in the accompanying Medical Document.
4. Registration with a Cannabis Regulations Licensed Producer (LP), on the basis of a Cannabis Regulations Registration Certificate, gives the Applicant the authority to possess or produce cannabis within the limitations of the certificate.
5. The Client will only use dried marihuana and/or cannabis oil obtained from Sensi Medical for his or her own medical purposes.
6. The information in this Application and the accompanying Medical Document is correct and complete.
7. The accompanying Medical Document or Cannabis Regulations Registration Certificate is not being used to seek or obtain medical cannabis from another source.
8. The Client acknowledges that neither dried cannabis and/or cannabis oil are approved therapeutic products, and that cannabis has not been authorized through the standard Health Canada drug approval process. This is because the current scientific evidence does not establish the safety and efficacy of cannabis to the extent required by the Food and Drug Regulations for marketed drugs in Canada.
9. The Client acknowledges that they are using medical cannabis products obtained from Sensi Medical at their own risk. The Client also specifically releases Sensi Medical (and its service providers, officers, directors, and staff) from any and all actions, claims, complaints and demands for damages, loss or injury whatsoever, whether arising directly or indirectly as a consequence of the use of Sensi Medical products or services.
10. In order to receive our products and services, the Client and/or Responsible Individual gives consent to Sensi Medical to disclose the necessary personal information to Sensi Medical service providers, Health Canada, Veterans Affairs, and/or insurance providers as applicable in accordance with Sensi Medical's Privacy Policy.
11. The Client consents that the Health Care Practitioner (HCP) named in this Application and accompanying Medical Document or Cannabis Regulations Registration Certificate may disclose to Sensi Medical the client's personal health information for the purposes of processing this registration application complying with the requirements of the Access to Cannabis for Medical Purposes (Cannabis Regulations). The client understands and agrees that a copy of this consent and Registration Application may be provided to the Health Care Practitioner named in this Application and accompanying Medical Document or Cannabis Regulations Registration Certificate.
12. The Client acknowledges that by signing this Registration Application form, you consent to receiving communications from us via email and similar electronic means. Should you wish to deal with us via a different channel or mechanism, you will need to make special arrangements for that by contacting us at 1-833-444-4664.
13. The Client acknowledges that their personal information may be accessible by third-party companies used by Sensi Medical.

By typing your name below and submitting this form, you acknowledge that you have read, understood and are agreeing to the terms above.

Print your full name to acknowledge and agree to the terms.

Date of agreement