APPLICATION TO BE A TIDAL HEALTH SOLUTIONS PATIENT PATIENT INFORMATION
All fields required unless otherwise noted. This form must be filled out by the patient (if patient is applying on his/her own behalf) or a caregiver (i.e. an individual responsible for the patient) applying on behalf of the patient. Caregivers must also complete the Caregiver Information form.
Patient Name *
Date of Birth * Email *
*Required for Online Shopping with Tidal Health Solutions Ltd.
* Phone * Fax (If Applicable)
*If the residence address above is not for a private residence, please indicate the following:
Name of Establishment Type of Establishment If you would like Tidal Health Solutions Ltd. to ship product to an address other than the Residence Address provided above, please check the option that applies: Shipping Address (If different from above residence address)
*Health Care Practitioner must consent to receive product by filling out Health Care Practitioner Information form.
Please check the option that applies: (Specific to patients applying on the basis of a Registration Certificate) THE PATIENT AND THE INDIVIDUAL RESPONSIBLE FOR THE PATIENT (IF APPLICABLE) MUST AGREE TO THE FOLLOWING: IMPORTANT, PLEASE READ AND SIGN BELOW.
The information contained in this registration application and the medical document, or registration certificate as applicable, is complete and has not been altered;
The applicant (patient) is ordinarily a resident in Canada;
The medical document, or registration certificate as applicable, used for this application is not being used
to seek or obtain dried cannabis or cannabis oil from another source;
The original of the medical document is provided in support of the application;
The applicant (patient) will use dried cannabis or cannabis oil only for their own medical purposes;
The indications, safety and risks of dried cannabis or cannabis oil use have not been adequately studied and the appropriate dosage is unclear. Patient and caregiver (if applicable) acknowledge(s) that any medical cannabis product obtained from Tidal Health Solutions Ltd. is done so at their own risk and release(s) Tidal Health Solutions Ltd., along with its affiliates, partners, providers, directors, officers, shareholders, employees and agents 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 products;
Tidal Health Solutions Ltd. makes no representations and gives no warranties or conditions, whether expressed, implied, statutory, or otherwise, including without limitation, any warranties or conditions of merchantable quality, durability, or fitness for a particular purpose, all of which are hereby disclaimed. That said, Tidal Health Solutions Ltd. takes its product quality seriously, as well as its obligations under the Cannabis Act and Regulations to investigate customer complaints. If at any time you have an issue, we encourage you to get in touch with us..
Patient and caregiver (if applicable) consent(s) to the health care practitioner named in his/her document disclosing required personal information to Tidal Health Solutions Ltd. for the purposes of complying with the requirements of the Cannabis Act and the Cannabis Regulations. Patient and caregiver (if applicable) understand(s) and agree(s) that a copy of this consent and registration application, as well as information about the patient’s registration status and usage patterns may be provided to the health care practitioner named in their medical document;
In the case where a responsible adult will be signing for the applicant (patient), they are responsible for that applicant;
Signature of Patient
If there is a caregiver, both patient and caregiver must sign this form unless the caregiver is the patient’s substitute decision maker (or equivalent) under applicable provincial law. If the patient does not sign, the caregiver, by signing below, attests that he or she is the patient’s substitute decision maker (or equivalent) under applicable provincial law.
Signature of Individual Responsible (if applicable)