Canada's Island Garden PEI

1-844-470-5500

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    Register

    Please complete all sections of the registration application below and submit the completed, signed and dated original application to Canada’s Island Garden Inc. You will need to send your completed medical documents by one of the following methods:

    1. mail the original completed Medical Document to us, signed and dated by your health care practitioner, or
    2. send by secure fax from your practitioner’s office, to 902-370-5501.

    All information on the application must match that on the Medical Document form. Incomplete forms will result in delay or denial of registration.

    *Note: If you wish for your order to be shipped to your health care practitioner, please refer to the printable form in Step 1 as a signature from the practitioner is required.

    • Section 1: Application Information

      To be completed by the applicant or by an individual who is responsible for the applicant, referred to in Section 2.
    • The address of the primary residence in Canada where the applicant ordinarily resides. (If this is not a private residence please complete the name and establishment information in Section 3)
    • Section 2: Individual Responsible for the Applicant

      To be completed by the individual who is responsible for the applicant. The responsible individual may act on behalf of the registered client. If the applicant would not like to authorize a person to act on the applicant’s behalf, this section may be left blank.
    • attest that I am an individual who is responsible for
    • 03/06/2021
    • Section 3: Residents of Shelters, Hostels or Similar Institutions (if applicable)

      To be completed by individuals who ordinarily reside at a places (care home, shelter, hostel or similar institution) in Canada, which provide social services to the applicant. If the applicant ordinarily resides at a dwelling place of permanent residence, this section may be left blank.
    • attest that my institution provides food, lodging or other social services to
    • 03/06/2021
    • Section 4: Health Care Practitioner Information

      Complete section 4 below with the information of the health care practitioner who provided the medical document to the applicant.
    • Section 5: Shipping Information

    • 03/06/2021
    • Section 6: Statement Of Applicant Or Responsible Individual

      To be completed by the applicant or the individual who is responsible for the applicant. NOTE: Carefully read all statements below before signing the application.
    • The undersigned applicant and/or responsible individual attests to the following: (1) The applicant is ordinarily a resident of Canada; (2) The information in the Registration Application and the Medical Document is correct and complete; (3) The medical document accompanying this application is not being used to seek or obtain dried marihuana from another source; (4) The original Medical Document accompanies this application; (5) The applicant will use dried marihuana for their own medical purposes; (6) The applicant acknowledges that dried marihuana is not approved for therapeutic use as a drug in Canada and that its use, indications, safety and risks have not been adequately studied, and the appropriate dosage is unclear. The applicant and/or individual who is responsible for the applicant acknowledges that the use of any marihuana for medical purposes product obtained from Canada’s Island Garden Inc., is done so at their own risk, and releases Canada’s Island Garden Inc. (including its directors, officers, employees and contractors) from any and all actions, claims, complaints, and demands for damages, loss, or injury whatsoever arising directly or indirectly as a consequence of the use of dried marihuana obtained from Canada’s Island Garden Inc. Release of Health Information Consent: By signing below, the applicant or individual responsible for the applicant consents to the disclosure of the applicant’s information to the Health Care Practitioner who has signed their medical document in order to process the application; to provide services or marihuana for medical purposes under the application to a registered client; and to comply with the Marihuana for Medical Purposes Regulations.
    • 03/06/2021
    • If you have any questions, please contact Canada’s Island Garden Inc. by PHONE at 902-370-5500 or EMAIL: info@canadasislandgarden.com
    • FORM-009-00

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