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Patient Registration
1. Patient Registration
2. Done
I am a patient
I am a caregiver
Caregiver Information
First Name
*
Middle Name
*
Last Name
*
DOB
*
Gender
*
Male
Female
Mobile Number
*
Email
*
Caregiver Residing Address
Address 1
*
Address 2 (Apt, Ste #)
City
*
Province
*
Alberta
British Columbia
Manitoba
New Brunswick
Newfoundland and Labrador
Northwest Territories
Nova Scotia
Nunavut
Ontario
Prince Edward Island
Quebec
Saskatchewan
Yukon
Postal Code
*
Do you reside at the same address as the patient?
*
Yes
No
Patient Information
First Name
*
Middle Name
Last Name
*
Email
*
Phone Number
*
DOB
*
Gender
*
Male
Female
Prefer not to say
K Number
Residing Address
Address 1
*
Address 2 (Apt, Ste #)
City
*
Province
*
Alberta
British Columbia
Manitoba
New Brunswick
Newfoundland and Labrador
Northwest Territories
Nova Scotia
Nunavut
Ontario
Prince Edward Island
Quebec
Saskatchewan
Yukon
Postal Code
*
Shipping Address
Is your shipping address the same as your residing address?
*
Yes
Patient Residing Address
No
Shipping Address
Address 1
*
Address 2 (Apt, Ste #)
City
*
Province
*
Alberta
British Columbia
Manitoba
New Brunswick
Newfoundland and Labrador
Northwest Territories
Nova Scotia
Nunavut
Ontario
Prince Edward Island
Quebec
Saskatchewan
Yukon
Postal Code
*
Is this shipping address a private residence?
*
Yes
No
Establishment Name
*
Signature
Date
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