Patient Registration

Create your account by completing the application form below

Patient Information

*Indicates required fields. The personal information provided on this Registration Form must match the information that appears on the Medical Document. For anyone completing this Registration Form on behalf of the Applicant, please complete the required section under Caregiver Information.

Coverage Information (if applicable)

Are you a Veteran? If yes, provide your K number below including the K. By indicating your K number, you give permission to Heritage Patient Care to share you details with Veteran's Affairs Canada.

If you are an existing C.A.R.P (Canadian Association of Retired Persons) member, enter your Membership # and expiry date DD/MM/YYYY. If you would like to become a new C.A.R.P. member, enter "SIGN UP FOR CARP" below.

Residential Address

Shipping Preference

Where should we ship your order to? Choose one:

*If you have requested to ship to the health care practitioner, please fill in their address as the shipping address

Shipping Address

N/A

Terms & Conditions

By signing below, the applicant or person responsible for the applicant, confirms and agrees to the following:

  • the applicant ordinarily resides in Canada,
  • the information in the application is correct and complete,
  • the medical document that forms the basis for the application has not, to the knowledge of the individual signing the statement, been altered,
  • the medical document is not being used to seek or obtain cannabis products from another source,
  • in the case where the applicant is signing the statement, they intend to use any cannabis product that is supplied to them on the basis of the application only for their own medical purposes, and
  • in the case where an adult who is named under the above section "Caregiver Information" is signing the statement, they are responsible for the applicant.
  • The indications, safety and risks of medical cannabis 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 Heritage is done so at their own risk and release(s) Heritage, 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.
  • Access to Cannabis for Medical Purposes Regulations (including disclosure of personal information to provincial licensing authorities upon request)” with the following text: “Cannabis Act (Canada) and the Cannabis Regulations, including disclosure of personal information to provincial licensing authorities upon request.
  • By signing this registration form, patient and caregiver (if applicable) allow Opticann by Heritage to (a) send medical cannabis product to the physical addresses provided therein, and (b) communicate via the email address provided regarding registration status, account information, purchases, order status, product availability and other matters in accordance with it's Privacy Policy.
  • I consent to receiving news, updates, exclusive offers, promotions and educational information from Opticann by Heritage via email. I understand I can withdraw my consent at any time by contacting Heritage Patient Care Team at 1-855-437-2266 or by unsubscribing.

By typing my name below and clicking [“Submit”], I acknowledge that I am providing my digital signature and I confirm and acknowledge the Terms & Conditions above.

(Type Your Name)

Click Submit only once. Your information will process.

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If you have any questions or comments, please do not hesitate to contact our Patient Care Team at 1-855-437-2266 during office hours Mon to Fri from 8:30am–6:00pm EST, or send us an email to: info@heritagecann.com.