Patient Registration FormFor access to medical cannabis Personal InformationName* First Last Date of Birth:* Date Format: DD slash MM slash YYYY Gender*MaleFemaleUnspecifiedPhone*Email* Do you currently have an active medical cannabis prescription?*Yes - via Hybrid PharmYes - via another sourceNoAre you having your medical document transferred from an existing licensed producer?*YesNoPrevious Licensed Producer*In selecting this box, I consent to transfer my existing medical document to Hybrid Pharm from my previous Licensed ProducerAre you a veteran?*YesNoK NumberPrimary AddressAddress* Street Address Address Line 2 City AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code Address type*PrivateEstablishment (nursing home, hospice, hospital)Name of Establishment*would you like to have your cannabis delivered to your healthcare provider at hybridpharm?*YesNoAddress Street Address Address Line 2 City AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code Is your shipping address different from your primary address?*YesNoShipping Address* Street Address Address Line 2 City AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code Do you have a caregiver?*YesNoCAREGIVER INFORMATIONCaregiver Name* First Last Caregiver Date of Birth:* Date Format: DD slash MM slash YYYY Caregiver Gender*MaleFemaleUnspecifiedCaregiver Address* Street Address Address Line 2 City AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code Caregiver Phone*Caregiver Email* PATIENT / CAREGIVER CONSENT The patient acknowledges that medical cannabis is not approved for the use as a drug in Canada, that its indications, safety and risks have not been adequately studied and the appropriate dosage is unclear. The patient acknowledges and agrees that they are using any medical cannabis product at their own risk, and releases hybridpharm inc. (and all its members) 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 medical cannabis obtained from hybridpharm inc. or any related sources. In order to receive products and services, the patient/caregiver authorizes consent to hybridpharm inc. to disclose necessary information to related parties, including licensed producers, health care practitioners and related healthcare members to be transmitted via phone, physical means, digital means or other, for the purposes of processing, patient registration and patient care. The applicant ordinarily resides in Canada. The information in the application is correct and complete. The medical document is not being used to seek or obtain cannabis products from another source. The applicant intends to use any cannabis product that is supplied to them on the basis of the application only for their own medical purposes. In the case where the applicant has named a responsible person, they are attesting to being responsible for the applicant. I have read the above statement and consent*YesType your name to confirm* First Confirmed on: 01/25/2021
