Online Registration

Register with AgMedica Bioscience Inc.

Thank you for selecting AgMedica Bioscience Inc. as your licensed producer of choice!

At AgMedica Bioscience Inc. our medical cannabis is produced in compliance with industry standards. All of our products are laboratory tested to ensure clients have access to safe and consistent products.

To become an AgMedica Bioscience Inc. client, you must complete this application in full. Our client care team are always available to answer any questions.

Important Information

AgMedica Bioscience Inc. is required to collect the following information of the Application pursuant to the Cannabis Act and Regulations (the “regulations”) and may be amended from time to time. AgMedica collects, uses and discloses personal information only in accordance with the provisions of the Personal Information Protection and Electronic Documents Act, the Ontario Personal Information Protection Act, the Cannabis Act and Regulations, and AgMedica’s Privacy Policy and only for the purpose of providing medical cannabis and related services to Applicants.

At any time, Applicants may access their personal information contained in AgMedica’s records and correct such information if necessary by submitting an Amendment Application to AgMedica.

Need Help During Registration?

Please contact our Client Care Team, toll-free, at 1-844-5MY-CARE (1-844-569-2273) if you require assistance while completing this application.

Application Form

Please note that the personal information provided on this form must match the information that appears on your Medical Document.

Applicant Information

Is this a new application or a renewal? If this is a renewal or amendment call or email Client Care and we will assist you.

FYI, if you are already registered, but need to renew or make an amendment, please download this form or contact Client Care.

Name
Date of Birth
Gender
Contact Information
Primary Phone
Secondary Phone
Email
Fax

Are you enrolled in the Veterans Affairs Canada Program?

Shipping and Mailing Address
* Must be in Canada, and cannot be Post Office Box
Residential Address

Is this also your mailing address?

Shipping Address

NOTE: This is the address we will ship your product to. The address must be either your residential address, the mailing address of the residence, or the business address of the physician or nurse practitioner who completed the Medical Document and has consented to receive medical cannabis on your behalf (please note: Applicants without a residential address must have their product shipped to the Healthcare Practitioner who completed their Medical Document.)



Non-Private Residence
* Required if address is non-private
Individuals Responsible for the Applicant
* To be completed by the individual responsible for the Applicant (if applicable)
Date of Birth
Gender
Physician or Nurse Practitioner
who Provided Medical Document to the Patient

HEALTHCARE PRACTITIONER’S CONSENT TO RECEIVE DRIED CANNABIS ON BEHALF OF PATIENT: (complete if applicable)

To be completed by a Healthcare Practitioner who provided Medical Document to the Patient, if they have consented to receive medical cannabis on behalf of the Patient:

Practitioner Name
Name of Patient
Address
Your Consent

By signing this document, you state that you understand, agree, and consent to each of the following statements:

  1. You ordinarily reside in Canada
  2. The information in this application and the accompanying Medical Document is correct and complete.
  3. The Medical Document, being submitted, is not being used to seek or obtain dried cannabis from another source.
  4. The use of dried cannabis is for your medical purposes ONLY.
  5. The original Medical Document is provided in support of the application.
  6. Medical cannabis is not currently approved for use as a pharmaceutical drug in Canada. You are using medical product obtained from AgMedica at your own risk. You hereby release AgMedica and its related entities from and all actions, claims, complaints, demands for damages, personal losses, and/or injuries arising directly or indirectly from the use of medical cannabis obtained from AgMedica.
  7. You understand that this consent is valid for the duration of the Registration Application/Medical Document submitted by the Client, unless you withdraw your consent earlier by sending a written request to AgMedica at: ClientCare@AgMedica.ca or by sending my request to: AgMedica Bioscience Inc., 111 Heritage Road, Suite 200, Chatham, ON., N7M 5W7

Would you like to receive email communications (promotions, newsletters, etc) from AgMedica through the contact information you have provided in your application?

By signing this Consent Form, you consent to AgMedica's collection, use and disclosure of the personal information contained in it, in accordance with AgMedica's Privacy Policy. This includes, without limitation, disclosure of this Consent Form, and related documents to the Healthcare Practitioner named in the client's Medical Document and the clinic or employee with which the Healthcare Practitioner works. Hard copies of the External Privacy Policy are available upon request. If the personal information in the Client Registration Application pertains to someone other than you, you represent and warrant that you have obtained their consent and/or have authority to consent on their behalf. Consent may be withdrawn at any time, but such withdrawal will not have retroactive effect. This withdrawal may have implications to you and/or the subject individual and will not affect the collection, use and disclosure of the personal information where such collection, use and disclosure is permitted or required by law without consent.

Signature