Register – Optimus Cannabis

Step 1: Patient Information

First Name *

Middle Name (optional)

Last Name *

Email *

Phone (optional)

Date of Birth *

Gender *

Are you a Veteran? *

Name of Insurance Provider (optional)

Insurance Policy Number (optional)

Name of Other Insurance Provider (optional)

Other Insurance Policy Number (optional)

Step 2: Address Information

Indicate if your primary address is *

Street Address *

Unit Number (optional)

Institute Name (optional)

City, Town, Village *

Province *

Postal Code *

Same Shipping Address *YesNo

Step 3: Institute Information

Street Address (optional)

Unit Number (optional)

Institute Name (optional)

City, Town, Village (optional)

Province (optional)

Postal Code (optional)

Manager Email (optional)

Manager Phone (optional)

Manager Secondary Phone (optional)

First and Last Name of Manager (optional)

Signature of Manager (optional)

Applicant Name (optional)

Application Date *

Signature of Healthcare Practitioner (optional)

Step 4: Person Responsible Information

Caregiver First Name (optional)

Caregiver Last Name (optional)

Caregiver Date of Birth (optional)

Caregiver Email (optional)

Caregiver Phone (optional)

Caregiver Secondary Phone (optional)

Caregiver Attest (optional)

Caregiver Full Name (optional)

Signature of Caregiver (optional)

Caregiver First Name (optional)

Caregiver Last Name (optional)

Caregiver Date of Birth (optional)

Caregiver Email (optional)

Caregiver Phone (optional)

Caregiver Secondary Phone (optional)

Caregiver Attest (optional)

Caregiver Full Name (optional)

Signature of Caregiver (optional)

Step 5: Agreement

I Agree *

By checking this box, you agree to the terms and conditions.

Signature *

Date (optional)