New patient registration

Your name(Required)

First Last

Email address(Required)

Phone number(Required)

Address(Required)

Street Address City Province Postal Code

Date of birth(Required)

Your gender(Required)

Female

Male

Your height(Required)

Your weight(Required)

Are you a veteran?(Required)

Yes

No

Do you currently have a doctor?(Required)

Yes

No

K number(Required)

If you are a veteran, please provide your K Number

Upload a copy of your identification card(Required)

Max. file size: 10 MB.

Who is your reference agent? How did you hear about Flodega?(Required)

How long have you been using cannabis for? (Years)(Required)

How many grams per day do you consume?(Required)

What forms of cannabis do you currently use or are interested in?

Terms and conditions(Required)

I agree to terms and conditions below

I am a resident of Canada.

The information provided is correct and complete.

This application is for the purposes of procuring cannabis products from Flodega Inc., DBA Lot 420.

I agree to make no claims or commence any legal action against the assessing physician/specialist/representative, my family physician, or any other involved person(s) in regards to both my consumption of medical cannabis and my application or medical document(s) for possessing, obtaining, cultivating and consuming medical cannabis.

I am fully aware that specialists & physicians generally agree that medical cannabis may affect sight, sounds, and the sensation of touch. It may impair thinking, problem solving, coordination, memory or learning. Medical cannabis may increase heart attack and reduce blood pressure, and could induce fear, anxiety, distrust or panic.

I am fully aware that medical conditions such as schizophrenia, atrial fibrillation, heart attack/stroke or use of blood thinners may result in the denial of my application to possess and consume medical cannabis. I am also aware that if pregnant or planning to become pregnant, medical cannabis should not be used during breastfeeding.

I am aware of the considerable debate and lack of consensus among physicians/specialists regarding the following topics: The appropriate dose and medical use of cannabis. The risks of burning medical cannabis compared to vaporizing or ingesting. The risks of burning extracted cannabinoids such as oil or hashish. The long term risk psychological and health risks associated with medical cannabis. The risks of pulmonary infections and respiratory cancer. The risks of triggering mental illness, such as bipolar disease or schizophrenia. The risk of nausea and disorientation.

I consent to the disclosure, sharing and use of my personal information and my personal health information by the assessing specialist/physician, and my licensed producer. The information may be used to contact and register the patient and may also be used anonymously for analytical and research purposes.

I truthfully believe that treating my personal medical condition(s) with medical cannabis potentially or has had a positive effect, and the benefits outweigh the potential risks associated. It is my personal decision to possess and consume medical cannabis and I do not support any claims made by family, friends, or other individuals against Flodega or the prescribing specialists/physicians.

I hereby release Flodega, our partners, the prescribing specialist/physician, other employees or team members, from any and all claims, actions, causes of actions, complaints (including friends and family), and demands for damages, losses, or injury arising directly or indirectly from my use of medical cannabis and/or my application to possess, cultivate, or consume medical cannabis.

If my prescription is approved, I agree not to resell or give away any of my medication. I have read and understood the limitations and regulations set forth by Health Canada. I agree to check with local bylaws in my area. I also agree that legal actions will take place in the province of Quebec, and be governed by the laws of Quebec, Canada.

This release from liability is to be binding on heirs, executors, agents and attorneys. I acknowledge that I have the right to disagree to these terms, canceling my application.

Email

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