Signup for Medical Cannabis

Same Day GTA Delivery

Sign-up to become a patient with WeedBx and the Solace Health Network. Same day delivery of medical cannabis in the GTA. Next day delivery in Ontario.

APPLICANT REGISTRATION FORM A

To be completed by the applicant or person responsible for the applicant and submitted to Solace Health Inc. at your earliest convenience.
First Name *

Last Name *
Birthday

Month

Day

Year
Gender
E-mail
Phone Number *

Area Code

Phone Number
Alt Phone Number

Area Code

Phone Number
Veterans K#
Residential Address Street Address Street Address Line 2

City

State / Province

Postal / Zip Code

Country
Street Address Street Address Line 2

City

State / Province

Postal / Zip Code

Country
If applicable, please complete the following.

First Name

Last Name

Phone Number

Area Code

Phone Number

Alt. Phone Number

Area Code

Phone Number

I hereby certify that I am responsible for the applicant.

Full Name
This constitutes your digital signature
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 SOLACE HEALTH IN ORDER FOR SOLACE HEALTH 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 SOLACE HEALTH AT HIS OR HER OWN RISK, AND RELEASES SOLACE HEALTH (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 SOLACE HEALTH. THE APPLICANT CONSENTS TO SOLACE HEALTH COLLECTING AND DISCLOSING NECESSARY PERSONAL INFORMATION IN ORDER TO PROCESS THIS REGISTRATION AND TO FULFILL ORDERS FOR MEDICAL CANNABIS IN ACCORDANCE WITH THE SOLACE HEALTH PRIVACY POLICY (HTTPS://SOLACE HEALTHCANNABIS.COM/PRIVACY-POLICY/). BY SIGNING BELOW, THE APPLICANT OR CAREGIVER ACKNOWLEDGES THAT THEY HAVE READ, UNDERSTOOD AND AGREE THAT: SOLACE HEALTH 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 SOLACE HEALTH 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 SOLACE HEALTH TO SHARE PERSONAL AND ORDER INFORMATION WITH VETERANS AFFAIRS CANADA. THE APPLICANT CONSENTS TO SOLACE HEALTH SENDING EMAIL, TEXT MESSAGE AND OTHER ELECTRONIC MESSAGING FROM SOLACE HEALTH 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 SOLACE HEALTH 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 SOLACE HEALTH, 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 SOLACE HEALTH 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.
Full Name *
This constitutes your digital signature
- Month - Day Year
Date *
REQUIRED *

By submitting this form, you agree to the above terms and conditions.
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APPLICANT REGISTRATION FORM A

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