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By registering with Emerald Health Therapeutics, you will benefit from over 60 years of cannabis growing knowledge in combination with our cutting-edge science. Our medical cannabis oils and dried cannabis are grown in small batches in our state-of-the-art facilities. Every batch of our cannabis is rigorously tested to ensure a consistent product and dosage for our patients.

Discover the difference for yourself.

Application for Medical Cannabis

SECTION 1: Applicant/Client Information

MaleFemaleUnspecified

CONTACT INFORMATION

(Primary residence must be in Canada. No PO box for contact info. May use below for mailing.)

NoYes (If yes, state business or facility name and type of business.)

MAILING ADDRESS

   (Check box If same as primary residence.)

SHIPPING ADDRESS

(Where you will receive Emerald Health Therapeutics Canada Inc. products.) Check appropriate box below.

SAME AS RESIDENTIALSAME AS MAILINGSHIP TO DOCTOR

If you select SHIP TO DOCTOR, please fill and submit an additional form found at emeraldhealth.ca/registernow.

CHECK BOX ONLY IF AN INDIVIDUAL RESPONSIBLE (OR FAMILY MEMBER) WILL BEMAKING DECISIONS/PLACING OR ASSISTING WITH ORDERS ON YOUR BEHALF
IMPORTANT

If yes, fill out caregiver information form found at emeraldhealth.ca/registernow and submit together with this application form.

ONLY if you are using a Registration Certificate issued by the Minister of Health (Part 2 of the ACMPR) rather than a Medical Document, check box.

I am registering for the purpose of obtaining an interim supply of Dried Cannabis or Cannabis Oil from Emerald Health Therapeutics Canada Inc. I am submitting a copy of my Registration Certificate.
I am interested in participating in a clinical study with Emerald Health Therapeutics.

SECTION 2: Certification Information

Whether you are the Applicant or the Individual Responsible for the Applicant, you need to sign this application form certifying that: » The Applicant ordinarily resides in Canada. » The information in this application and the accompanying Medical Document or Registration Certificate issued by the Minister under Part 2 is correct and complete. » The Medical Document or Registration Certificate is not being used to seek or obtain fresh or dried marihuana or cannabis oil from another source. » The original of the Medical Document, or a copy of the Registration Certificate, accompanies this application. » The Applicant will use fresh or dried marihuana or cannabis oil only for their own medical purposes. » The Applicant consents to the healthcare practitioner named in the accompanying Medical Document disclosing required personal health information to Emerald Health Therapeutics Canada Inc. for the purposes of complying with the requirements of the Access to Cannabis for Medical Purposes Regulations. » The Applicant (or Individual Responsible) acknowledges that he / she has read and agrees to Emerald Health Therapeutics Canada Inc.’s Terms & Conditions and Privacy Policy, available at www.emeraldhealth.ca. The Applicant (or Individual Responsible) further acknowledges that medical marihuana or cannabis oil is not approved for use as a pharmaceutical drug in Canada, and that its indications, safety and risks have not been adequately studied and the appropriate dosage is not clear. The Applicant (or Individual Responsible) acknowledges and agrees that he / she is using any medical marihuana or cannabis oil obtained from Emerald Health Therapeutics Canada Inc. at his / her own risk and releases Emerald Health Therapeutics Canada Inc. 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 marihuana or cannabis oil obtained from Emerald Health Therapeutics Canada Inc. » The Applicant authorizes Emerald Health Therapeutics Canada Inc. to send emails as part of the relationship (note: this is required to order online). » Emerald Health Therapeutics Canada Inc. makes no representations and gives no warranties or conditions, whether express, implied, statutory, or otherwise, including, without limitation, any warranties or conditions of merchantability, merchantable quality, durability, or fitness for a particular purpose, all of which are hereby disclaimed. Emerald Health Therapeutics Canada Inc. takes its products very seriously, as well as its obligations under the ACMPR to investigate all customer complaints. If at any time you have an issue with your Emerald Health Therapeutics Canada Inc. medical marihuana or cannabis oil, we encourage you to contact us.

IMPORTANT

Applicant (or individual responsible for Applicant) must SIGN, Print Name and Date Below.

NOTE: Individual responsible for the Applicant must complete caregiver form and sign and date the attestation indicating you are responsible for the Applicant.

Applicant or Individual WHO IS Responsible for Applicant

EMERALD HEALTH THERAPEUTICS CANADA INC. 310-777 Royal Oak Drive, PO Box 24076, Victoria, BC V8X 4V1 Canada. For the fillable form PDFs, please visit emeraldhealth.ca/registernow. NOTE: Your doctor’s office may fax the original Medical Document (and application) to 1.855.623.3325 or you may mail or courier the original medical document to us.

Contact Our Team


Emerald has assembled a highly
skilled Client Care team that's
here to assist you.
Please call us toll free at 1.800.757.3536.
or please email us at: clients@emeraldhealth.ca

Have questions? We've got answers.

Our extensive FAQs take the guesswork out of registering.