Online Registration Name* First Last Email* Address* Street Address Address Line 2 City AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code Phone*Date Of Birth*Medical Condition(s) and Symptoms*Physician's NameAre you presently taking any prescription pharmaceuticals?NoYesIf so, please list your drug regimen as well as any side effects:How long have you been using Cannabis?How long have you been using Cannabis as a medicine?How does Cannabis affect your symptoms?How often do you use Cannabis?Does this dosage alleviate your symptoms?For the documents needed below, you can either scan them OR take a picture of your documents and then attach them by clicking the button for each.Government issued ID*Dispensary CardPrescriptionOkanagan Herb Membership Term and Agreement: • I affirm that I have a medical condition that adversely affects my quality of life. Medical cannabis provides substantial relief and improvements of my condition. I will not be reselling any products purchased from Okanagan Herb. • I understand that the benefits and risks associated with the use of medical cannabis is not fully understood and may involve risks that may not be identified. • I am aware that cannabis use is restricted for medical usage and it is currently illegal for recreational purpose. I hereby designate you to act as my agent to procure medical cannabis on my behalf for my own medical use. • I agree to you use medical cannabis responsibly and will not operate heavy machinery, motor vehicles, or transport outside of Canada • I understand Okanagan Herb does not guarantee any health or medical claims. I agree for myself, my heirs and executors to waive any and all claims for any cause or reason against Okanagan Herb, its owners and its employees. Signature**BY SIGNING ABOVE YOU DECLARE THAT THE INFORMATION YOU HAVE PROVIDED ON THIS FORM IS FACTUAL AND THAT YOU AGREE TO ALL THE ABOVE AGREEMENT AND TERMS:*CaptchaHow Did you hear about Okanagan Herb?