Register - Canada's Island Garden PEI

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:

mail the original completed Medical Document to us, signed and dated by your health care practitioner, or
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.
Name*
First Middle (if applicable) Last
Date of Birth*
Gender*
- Male
- Female
Email
Enter Email Confirm Email
Phone*
Preferred Contact Method*
Preferred Contact Time*
Primary Residence*
Street Address Address Line 2 City Province Postal Code

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)
Is your mailing address is different then above?*
- No
- Yes
Shipping Address (if different from above)*
Street Address Address Line 2 City Province Postal Code
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.
An authorized person will be acting on my behalf.*
- No
- Yes
Name
First Last
Date of Birth*
Month
Day
Year
Gender*
- Male
- Female
Phone*
Email
Enter Email Confirm Email
I (Name of Responsible Individual)*
First Last
attest that I am an individual who is responsible for
Name of Applicant*
First Last
Responsible Individual Signature*
06/22/2021
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.
Are you currently a resident of a shelter, hostel or similar institution?*
- Yes
- No
Institution Name*
Institution Type*
Institution Address*
Street Address Address Line 2 City Province Postal Code
Email
Enter Email Confirm Email
Phone*
I (Name of Institution’s Manager)*
First Last
attest that my institution provides food, lodging or other social services to
Name of Applicant*
First Last
Manager’s Signature*
06/22/2021
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.
Health Care Practitioner’s Name (Full name, no initials)*
Prefix First Last
Business Address*
Street Address Address Line 2 City Province Postal Code
Section 5: Shipping Information
Confirm Shipping Address*
- Select this box if shipping address is the same as the Primary Residence Address provided above.
- Select this box if shipping address is the same as the Mailing Address (if different than Primary Residence Address) provided above.
06/22/2021
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.
Applicant Signature*
Responsible Individual Signature (if applicable)*
Date*
Month
Day
Year
06/22/2021
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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Section 1: Application Information

Section 2: Individual Responsible for the Applicant

Section 3: Residents of Shelters, Hostels or Similar Institutions (if applicable)

Section 4: Health Care Practitioner Information

Section 5: Shipping Information

Section 6: Statement Of Applicant Or Responsible Individual

FORM-009-00