Patient Registration

All fields required unless otherwise noted. This form must be filled out by the client (if you are applying on your own behalf) or a caregiver (i.e an individual responsible for the client) applying on behalf of the client. Responsible Adults must also complete the Responsible Adult information form.

Patient Information

First Name:

Last Name:

Date of Birth:

If applicant is under the age of majority, please fill out the section to indicate a Responsible Adult.

This applicant is under the care of a responsible adult

Email:

Residence

Address:

City/Town:

Province:

Postal Code:

Mailing Address

Mailing address same as above

Mailing Address:

City/Town:

Province:

Postal Code:

Veterans

I am a Canadian Veteran

Shipping Preferences

If you would like ECO to ship product to an address other than the Residence Address provided above, please check the option that applies. Note that if shipping to a Health Care Practitioner, the practitioner must consent to receive product by filling out Health Care Practitioner Information form below.

Ship to my residence address

Ship to my mailing address

Ship to my health care practitioner

How did you hear about us?

Agreement

Important: please read and sign below.

The information contained in this registration application and the medical document, or registration certificate as applicable, is correct and complete;
The applicant (client) 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 cannabis from another source;
The original of the medical document is provided in support of this application;
The applicant (client) will use dried cannabis only for their own medical purposes;
The indications, safety and risks of cannabis use have not been adequately studied and the appropriate dosage is unclear. Client and caregiver (if applicable) acknowledge(s) that any medical cannabis product obtained from ECO is used so at their own risk and release(s) ECO, along with its affiliates, partners, providers, directors, officers and employees 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;
Client and Responsible Adult (if applicable) consent(s) to the health care practitioner named in their document disclosing required personal information to ECO for the purposes of complying with the requirements of the Cannabis Act. and Regulations. Client and caregiver (if applicable) understand(s) and agree(s) that a copy of this consent and registration application, as well as information about the client's registration status and usage patterns may be provided to the health care practitioner named in their medical document;
Client and Responsible Adult (if applicable) consent(s) to ECO's collection, use and disclosure of necessary personal information in order to process this registration, to provide products or services, to comply with the Cannabis Act and Regulations (including disclosure of personal information to provincial licensing authorities upon request), and otherwise in accordance with ECO's Privacy Policy. By signing this registration form, client and Responsible Adult (if applicable) allow(s) ECO to (a) send product and registration information to the physical and email addresses provided therein, and (b) communicate with them via email regarding registration status, product availability, order status, and other matters in accordance with ECO’s Privacy Policy.

Signature:

I agree that my electronic signature is the legal equivalent of my manual signature on this Agreement.

Date:

Responsible Adult First Name:

Responsible Adult Last Name:

Date of Birth:

Telephone:

Email:

Required for ECO online ordering

I am responsible for the applicant named on this form.

Signature of Responsible Adult:

I agree that my electronic signature is the legal equivalent of my manual signature on this Agreement.

Date:

Health Care Practitioner Information

This section must be completed by the Health Care Practitioner who provided the medical document if they consent to receiving cannabis on behalf of the patient.

Health Care Practitioner Title:

Health Care Practitioner First Name:

Health Care Practitioner Last Name:

Where should the product be shipped to?

Shipping Address:

City/Town:

Province:

Postal Code:

I consent to receive cannabis on behalf of the applicant named on this form.

I agree that my electronic signature is the legal equivalent of my manual signature on this Agreement.

Date

Submit

Patient Registration

Age Verification