Add New Patient

Registration Document

Medical Document

Patient Profile

I have consented to disclose the personal health information of this patient, consisting of: Dose information of marijuana used for medical purposes, as a verification of the health care practitioner’s orders, as required to Starseed Limited.

Applicant's Information

Email Email

No Email Provided

First Name First Name

Last Name Last Name

Gender

Date of Birth Date of Birth

Telephone Telephone

How did you hear about us?

Referral By (Optional) Referral By (Optional)

Veteran K Number (Optional) Veteran K Number (Optional)

Department

Registration Document

Personal Information

Are you the applicant?

Yes No

Caregiver Information

To be completed if you are the individual responsible for the applicant and are completing the Registration Application of the behalf of the applicant.

Number of Caregivers

1 2

Caregiver #1 Information

First Name First Name

Last Name Last Name

Date of Birth Date of Birth

Telephone Telephone

I am responsible for the applicant

Caregiver's Signature – Sign via touch

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Date Date

Caregiver 2 Information

First Name First Name

Last Name Last Name

Date of Birth Date of Birth

Telephone Telephone

I am responsible for the applicant

Caregiver's Signature – Sign via touch

Reset

Date Date

Residence Address

Have a permanent address?

Yes No

Type of Address

Establishment Name Establishment Name

Manager's Name Manager's Name

Establishment Type Establishment Type

Address Line 1 Address Line 1

Address Line 2 Address Line 2

City City

Province

Postal Code Postal Code

Telephone Telephone

Email/Fax # (if applicable) Email/Fax # (if applicable)

I would like you to leave a voicemail if I am not home:

Yes No

Use residence address as shipping address

Alternative Mailing Address

Have an alternative mailing address?

Yes No

Type of Address

Establishment Name Establishment Name

Establishment Type Establishment Type

Manager's Name Manager's Name

Address Line 1 Address Line 1

Address Line 2 Address Line 2

City City

Province

Postal Code Postal Code

Telephone Telephone

Email/Fax # (if applicable) Email/Fax # (if applicable)

Use alternative address as shipping address

Healthcare Practitioner Address

Ship to healthcare practitioner address?

Yes No

First Name First Name

Last Name Last Name

Address Line 1 Address Line 1

Address Line 2 Address Line 2

City City

Postal Code Postal Code

Province

Telephone Telephone

Email/Fax # (if applicable) Email/Fax # (if applicable)

Healthcare Practitioner Signature – Sign via touch

Reset

Date Date

Union and Insurance

Is the applicant a union member?

Yes No

Employer Program / Union

Status / Local

Member Type

Insurance Company Insurance Company

Group Insurance Number Group Insurance Number

Member Number Member Number

Member Full Name Member Full Name

Last two numbers of drug card Last two numbers of drug card

Preference of Contact

Licensed Producer/Seller Name Licensed Producer/Seller Name

Licensed Producer/Seller Phone Number Licensed Producer/Seller Phone Number

Email Email

Telephone Number Telephone Number

Fax Number Fax Number

Are you under other benefits plan?

Yes No

Start Date Start Date

Company Company

Policy Number Policy Number

Drug Card Number Drug Card Number

Does the patient have drug coverage under any other group benefits plan?

Yes No

Start Date Start Date

Company Company

Policy Number Policy Number

Member Number Member Number

Name of Plan Member Name of Plan Member

Relationship to Patient Relationship to Patient

Provide details and attach documentation of acceptance or decline Provide details and attach documentation of acceptance or decline

Is the patient currently on, or previously been on this drug?

Yes No

Start Date Start Date

Coverage Company Coverage Company

*if coverage is not provided by Canada Life please provide pharmacy print-out showing purchase of this drug.

Does the patient have coverage under a provincial program or from any other source?

Yes No

Name of program or other source Name of program or other source

Provide details and attach documentation of acceptance or decline Provide details and attach documentation of acceptance or decline

Is the patient currently receiving disability benefits for the condition for which this drug has been prescribed?

Yes No

Has the patient enrolled in the patient assistance program for this drug?

Yes No

Patient assistance program patient ID number Patient assistance program patient ID number

Contact Person Name Contact Person Name

Phone Number Phone Number

Benefit Document:

Authorization of Applicant

As applicant or a responsible individual you acknowledge, attest, agree and consent to the following:

(i) the applicant ordinarily resides in Canada
(ii) the information in the application is correct and complete
(iii) the medical document that forms the basis for the application has not, to the knowledge of the individual signing the statement, been altered
(iv) the medical document is not being used to seek or obtain cannabis products from another source
(v) 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
(vi) in the case where an adult who is responsible for the applicant is signing the statement, they are responsible for the applicant.

The applicant acknowledges that cannabis and/or cannabis oil is not an approved therapeutic product and cannabis has not been authorized through the standard Health Canada drug approval process because the available scientific evidence does not establish the safety and efficacy of cannabis to the extent required by the Food and Drug Regulations for marketed drugs in Canada.

The applicant acknowledges that they are using any medical cannabis or related product obtained from WeedMD RX Inc. at their own risk. The applicant also specifically releases WeedMD RX Inc. (and its service providers, officers, directors and staff) from any and all actions, claims, complaints and demands for damages, loss or injury whatsoever, whether arising directly or indirectly as a consequence of the use of Starseed’s products or services.

In order to receive our products and services, the applicant or authorized person gives consent to WeedMD RX Inc. to disclose the necessary personal health information to Starseed’s service providers, including North Star Wellness Inc., and including without limitation, the health care practitioner named in this registration, in accordance with Starseed’s Privacy Policy (www.starseed.com/privacy/).

The applicant and/or authorized person consents to the health care practitioner named in this registration application disclosing to WeedMD RX Inc. the applicant’s personal health information by phone, physical means or digital means (including Starseed’s online portal or SFax secure system) for the purposes of processing this registration (which may include the submission of my Medical Document by digital means), client service and complying with the requirements of the Cannabis Regulations. The applicant understands and agrees that a copy of this consent and registration application may be provided to the health care practitioner named in this registration.

Establishment Manager's Signature – Sign via touch

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Date Date

Applicant/Responsible Individual's Signature – Sign via touch

Reset

Date Date

Patient Medical

Medical Requirements

Quantity (grams/day) Quantity (grams/day)

Duration Duration

Period

THC Limit (optional) THC Limit (optional)

Medical Diagnosis (optional)

Clinic

Referred By Clinic

Referred by Practitioner

Referred By 3 Referred By 3

Referred By 4 Referred By 4

Referred By 5 Referred By 5

Products Type Limit (optional)

Dried Cannabis Limit Dried Cannabis Limit

Cannabis Oil Limit Cannabis Oil Limit

Vapes Limit Vapes Limit

Topicals Limit Topicals Limit

Edibles Limit Edibles Limit

Prescribe Products

Dried Cannabis

Cannabis Extract - Inhalation

Cannabis Extract - Ingestion

Cannabis Topicals

Consultation Address

Applicable?

Yes No

Address Line 1 Address Line 1

Address Line 2 Address Line 2

City City

Province

Postal Code Postal Code

Practitioner's Signature – Sign via touch

Reset

Save as my default signature

Date Date

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