Membership Form

Application Requirements

After you fill out this online application, you MUST show valid, original photo identification AND submit one of the following:

  • Documentation of your health condition from an eligible medical practitioner, or
  • A valid membership card from another dispensary with your full, legal name printed on it (membership cards with just a number are NOT accepted!).

Which location do you wish to submit your documentation / membership card at?

 

Applicant's Information

Applicant's Name:
Date of Birth:

MMAR # (if applicable):

Address:

City:

Province:

Postal Code:

Phone Number:

Email:

Medical Conditions and Symptoms:

Please check the box for any medical conditions you may have:

ADHD
AIDS/HIV
Anxiety/Stress Disorder
Arthritis
Asthma
Brain/Head Injury
Cancer
Cerebral Palsy
Chronic Pain
Colitis
Crohn's Disease
Depression
Eating Disorders
Eczema
Emphysema
End of life/Palliative care
Epilepsy
Fibromyalgia
Glaucoma
Hepatitis C
Irritable Bowel Syndrome
Chronic Migraine
Multiple Sclerosis
Muscular Dystrophy
Nausea - Chronic, debilitating
Neuralgia
Paraplegia/Quadriplegia
Psoriasis
Parkinson's Disease
Radiation Therapy
Seizure Disorders
Sleep Disorders
Spinal Cord Injury
Other medical conditions:

Please note: When you pick up your membership card, you must show your photo ID. No exceptions.

Some medical conditions require more attention and may require an explicit recommendation of use from a medical practitioner. Please check the box below for any of the following medical conditions you may have.

Addiction
Schizophrenia
Withdrawal
Bi-Polar
Pregnancy
None


Name (please print clearly)

Signature

Date

 

 

CODE OF CONDUCT

PLEASE CHECK EACH BOX AFTER READING.
VIOLATION OF THESE CODES OF CONDUCTS WILL RESULT IN A TEMPORARY OR PERMANENT SUSPENSION OF SERVICES.

NO RESELLING. NO SHARING. We provide medical cannabis for you only. Any reselling or sharing of your medicine is forbidden. If you are caught reselling any products purchased from The Herb Co., you will be permanently banned from receiving services.

BE POLITE. We are doing our best to provide a service to our clients. Please treate the staff and other members of The Herb Co. with politeness and respect.

BE RESPONSIBLE. Use your medicine in a respectful and responsible way. Smoking cannabis should be done in private, not in public.

KEEP US INFORMED. Please let us know about any quality issues you have with our products. Good or bad, please let us know what works and what doesn't work.

NO SMOKING on or near dispensary locations. Do not smoke cannabis within 100 feet of dispensary locations.

DO NOT TRANSPORT ANY CANNABIS OUT OF CANADA.

CAUTIONS

IMPAIRMENT: Cannabis may potentially cause a temporary decrease in coordination and cognitive abilities and short-term memory loss while medicated. Do not drive or operate heavy machinery if impaired by cannabis products. Be especially careful of impairment when eating cannabis products or using extracts. Do not eat cannabis products before swimming or drinking.

ALCOHOL: Cannabis mixed with alcohol may cause vomiting and nausea. We recommend limiting or stopping your intake of alcohol when using cannabis products.

IRRITATION: Heavy smoking with no harm reduction techniques may lead to respiratory irritation.

BLOOD PRESSURE: Initial increase in heart rate and/or blood pressure may be problematic for those with heart conditions or severe anxiety. Those receiving digitalis or other cardiac medications should use cannabis under careful supervision by a medical doctor.

WITHDRAWAL: There are no significant withdrawal effects when cannabis use is ceased or decreased; however, minor restlessness, nausea, and fatigue may be experienced. Symptom relief will also cease or be decreased.

THE LAW: Unless you have a federal exemption, it is illegal in Canada to posses , grow, or distribute cannabis. Know your rights and take precautions to avoid the harmful effects of arrest, cannabis seizure, imprisonment, and criminal record.

ACKNOWLEDGEMENT

I accept that The Herb Co. makes no guarantees or medical claims; and I hereby agree for myself, my heirs, and executors to waive any claims against The Herb Co. and its employees.

have read this form and agree to abide by the code of conduct and cautions listed above.

Name (please print clearly)

Signature

Date

 

THE HERB CO. NEWSLETTER

Would you like to receive The Herb Co.'s newsletter and special promotions? Please indicate your preference by ticking one of the boxes below.

I wish to be contacted by:

Email
Phone (Text)
Email and Phone (Text)
I do not wish to be contacted by email or phone.


PERSONAL INFORMATION COLLECTION

The Herb Co. will use the personal data collected from you for the purpose of confirming your identity, ensuring up-to-date information, and verifying your diagnosis and recommendations of use.

We intend to use your email address and/or phone number for the purpose of informing you of special circumstances and/or events. We cannot use your personal data unless we have received your consent or indication of no objection. I wish to be contacted by:

Email
Phone (Text)
Email and Phone (Text)

We will not provide your personal data to third parties for direct marketing or unrelated purposes.



SURVEILLANCE

To ensure the safety of all staff and members of The Herb Co., all areas on dispensary premises will be under 24-hour camera and audio surveillance (real-time monitoring).

I have read and understand the policies stated above.

By signing below I am declaring that I agree with the terms of membership with The Herb Co. Medical Cannabis Dispensary.

Name (please print clearly)

Signature

Date