GreenRelief Patient Registration Thank you for choosing Green Relief as your provider of medical cannabis. To register as a client, this form must be completed in full by the applicant or the caregiver responsible for the applicant’s care. When submitting this form (by mail or fax), you must also include a completed Medical Document signed and dated by your Health Care Practitioner. Are you registering for the first time or renewing*New RegistrationRenewalAmple Client ID*16 Digit Pin Including dashes, eg. 1234-1234-1234-1234Applicant Information*I am applying on my own behalf.I am a caregiver, completing the registration on behalf of the Applicant.First Name*Last Name*Date of Birth* Gender*MaleFemaleN/AResidence Address*City*Province*AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland & LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukonPostal Code*Telephone*FaxEmail* My mailing address is different than my residence address.YesNoMailing Address*City*Province*AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland & LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukonPostal Code*The above Residence Address is a*Private ResidenceEstablishmentName of Establishment*Type of Establishment*Address*Phone*FaxEmail* To be completed by the manager of the specified Establishment.I,*hereby confirm that*provides, food, lodging or other social services to*Managers Signature*Date* Where will Green Relief be shipping your medical cannabis?*Residence AddressMailing AddressHealth PractitionerEstablishment Specified AboveCaregiver InformationThe "Applicant" is the person who the medical cannabis is for. The "Caregiver" is defined as the responsible decision-maker in the patient's care and is filling out this form on behalf of the Applicant. The Caregiver must complete both Application Information section (above) and Caregiver Information section (below).First Name*Last Name*Date of Birth* Telephone*Date* Authorization of Application - As the Applicant or Caregiver responsible for the Applicant, you attest, agree and consent to the following: the Applicant is a permanent resident in Canada; the information in the Registration Form and the Medical Document is correct and complete; the Medical Document is not being used to seek or obtain dried cannabis and/or cannabis oil from another source; the original of the Medical Document accompanies the application; and the Applicant will use dried cannabis and/or cannabis oil only for their own medical purposes The Applicant acknowledges that dried cannabis is not an approved therapeutic product and cannabis has not been authorized through the standard Health Canada drug approval process because the available 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. The Applicant acknowledges that they are using any medical cannabis or related product obtained from Green Relief Inc. at their own risk. The Applicant also specifically releases Green Relief Inc. (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 Green Relief Inc.’s products or services. In order to receive our products and services, the Applicant or authorized person gives consent to Green Relief Inc. to disclose the necessary personal information to Green Relief Inc.’s service providers, including the Health Care Practitioner named in this registration. The Applicant and/or Authorized Person consents to the Health Care Practitioner named in this registration form disclosing to Green Relief Inc. the Applicant’s personal health information by phone, physical means or digital means (including Green Relief Inc.’s online portal or secure fax system) for the purposes of processing this registration (which may include the submission of my Medical Document by digital means), client service and 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 and registration application may be provided to the Health Care Practitioner named in this registration.Applicant Signature*Signature Date* Caregiver Signature*Signature Date* * I hereby acknowledge that I am the Caregiver responsible for the care of the Applicant CommentsThis field is for validation purposes and should be left unchanged. This iframe contains the logic required to handle Ajax powered Gravity Forms.