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Registration  Amendment Form

Changing Address, Email, Phone and Fax Numbers

Use the Registration Amendment form below or send us a Registration Amendment form.

Changing Name, Gender, or Date of Birth

To change your name, gender, or date of birth please send us a Registration Amendment form accompanied with official documentation of the change. Once we verify and apply the changes, we will send you a new CanniMed Client Registration Document via mail and/or email.

Changing Caregiver

To change the person responsible for the client please send us a Registration Amendment form accompanied by a signed and dated statement from the individual responsible. Once we verify and apply the changes, we will send you a new CanniMed Client Registration Document via mail and/or email.

Updating your Health Care Practitioners Address

To update your Health Care Practitioners address please send us a Registration Amendment form accompanied by a signed and dated consent to receive product from your Health Care Practitioner. Once we verify and apply the changes, we will send you a new CanniMed Client Registration Document via mail and/or email.

Other

If there is any other account info you would like to update please send us a Registration Amendment form. Once we verify and apply the changes, we will send you a new CanniMed Client Registration Document via mail and/or email.

If you have any other questions, you can also reach us at 1-855-787-1577 or at info@cannimed.com.

Registration Amendment Form

Your browser does not support this Amendment Form. To access this form please try another browser, or download and manually submit the form, or contact us at 1-855-787-1577 or info@cannimed.com.

Applicant Information

* Client Name :  
* CanniMed client number :  

Please select which situation applies to you

Declaration of the Applicant or the Person Responsible For the Applicant

  • The client is ordinarily a resident in Canada.
  • The information in the application is correct and complete.

Applicant/Person responsible for Applicant signature

Please sign in the box above. It is difficult to replicate your exact signature using a mouse or touch pad. Just try your best.