Patient Registration

Follow the simple steps below to complete your registration.

How it Works

Become a patient today.
Easy as 1-2-3.

Book an appointment

You will need to see a Health Care Practitioner in order to assess your eligibility for access to medical cannabis. We are proud to partner with Canabo Medical Clinic to make this a smooth process.

Register with us

Once you have spoken with a Health Care Practitioner and obtained a medical document, you can complete our online registration form to set up your account.

Purchase medical cannabis

After registration is complete, you or an Individual Responsible can begin to order products through our online marketplace and we’ll ship them directly to you.

Patient Information

First Name(Required)

Last Name(Required)

Date of Birth(Required)

MM slash DD slash YYYY

Language(Required)

English

French

Gender(Required)

Male

Female

Other

Email(Required)

Phone(Required)

Fax (Optional)

Are you a veteran?(Required)

Yes

K Number(Required)

Primary Address

Street Address(Required)

City(Required)

Province(Required)

Postal Code(Required)

Is your primary address the same as your Shipping Address?(Required)

Yes

Shipping Information

Street Address(Required)

City(Required)

Province(Required)

Postal Code(Required)

Application Information

Are you filling out this form on behalf of someone else?(Required)

Yes (I am a caregiver / manager of institution / healthcare practitioner)

No (I am filling out this form for myself)

Caregiver / Manager of Institution / Healthcare Practitioner

Non-Primary Residence Type(Required)

Caregiver: I am responsible for the Applicant

Manager of Institution: I attest that the institution provides food, lodging, or other social services to the Applican

Healthcare Practitioner: I consent to receive medication on behalf of the Applicant

Other

Establishment Name

Establishment Type

Relationship to Applicant(Required)

First Name(Required)

Last Name(Required)

Date of Birth(Required)

MM slash DD slash YYYY

Gender(Required)

Male

Female

Other

Email(Required)

Phone(Required)

Signature(Required)

*Signature to be provided by ONLY the Manager of Institution or Healthcare Practitioner accepting medication on behalf of the Applicant.

Authorization

By signing below, the Applicant or Caregiver for the Applicant acknowledges that they have read, understood and agree that the Applicant ordinarily resides in Canada. The information in this application and the accompanying Medical Document or registration certificate is correct and complete. The Medical Document or registration certificate is not being used to seek or obtain medical cannabis from another source. The original Medical Document MUST be received by Emblem in order for Emblem to complete the patient registration. The Applicant will use medical cannabis only for their own medical purposes. The Applicant understands and acknowledges that medical cannabis is not currently approved for use as a pharmaceutical drug in Canada. The Applicant acknowledges and agrees that he or she is using any medical cannabis product obtained from Emblem at his or her own risk, and releases Emblem (and its partners, providers, officers, directors and staff) from any and all actions, claims, complaints and demands for damages, loss or injury whatsoever arising directly or indirectly from the use of medical cannabis obtained from Emblem. The Applicant consents to Emblem collecting and disclosing necessary personal information in order to process this registration and to fulfill orders for medical cannabis in accordance with the Emblem privacy policy (www.emblemcannabis.com/clientprivacypolicy). By signing below, the Applicant or Caregiver acknowledges that they have read, understood and agree that: Emblem may from time to time use personal health information (i.e. your condition(s), product selection) on an anonymous and aggregate basis for research and/or medical educational purposes. We may also ask you to complete surveys that we use for research purposes, although you do not have to respond to these. The Applicant consents to their health care practitioner named in the Medical Document disclosing required personal health information to Emblem for the purposes of complying with the requirements of the Access to Cannabis for Medical Purposes Regulations (ACMPR). The Applicant or Caregiver understands and agrees that a copy of this consent and registration application may be provided to the health care practitioner. By indicating the Applicant is a veteran, the Applicant or Caregiver hereby gives permission for Emblem to share personal and order information with Veterans Affairs Canada. The Applicant consents to Emblem sending email, text message and other electronic messaging from Emblem and their respective subsidiaries, affiliates, business brands and marketing partners. The Applicant understands that they may withdraw their consent at any time. Patient hereby acknowledges and agrees that Emblem does not make any representations or warranties with respect to the quality and fitness of any promotional or ancillary product(s) provided and/or sold by Emblem, and shall not be liable for any damages direct or indirect that may occur as a result of its use. Please note that the Confirmation of Registration Form is proof of legal possession and the Patient Card that you may receive from Emblem is not proof of legal possession. You may be required to provide either your patient label on your original packaging and/or the Confirmation of Registration to prove legal possession within Canada only.

First Name(Required)

Last Name(Required)

Signature(Required)

Patient Registration

Become a patient today. Easy as 1-2-3.

Book an appointment

Register with us

Purchase medical cannabis

Patient Information

Primary Address

Shipping Information

Application Information

Caregiver / Manager of Institution / Healthcare Practitioner

Authorization

Become a patient today.
Easy as 1-2-3.