Patient Registration Form

Patient Registration Form

To become an Aqualitas Patient, complete the registration form below, or click here to print the paper version based on this online form if you have difficulties submitting online.

Your information is completely private and secure. Your response will be captured and sent directly to our Client Care staff via e-mail in an encrypted PDF attachment format. Your responses will not be stored on our website's servers. To get a decrypted copy of your application for your records please contact Client Support at clientsupport@aqualitas.ca after submission, using the same e-mail address as disclosed in your submitted contact information.

Click the heading of each section to reveal the form fields.

Client Information

All fields required unless otherwise noted. This form must be filled out by the client (if you are applying on your own behalf) or a caregiver (i.e. an individual responsible for the client) applying on behalf of the client. Responsible Adults must also complete the Responsible Adult information form.

Residential Address

Mailing Address

(If different from above residence address.)

Signed Agreement

The client and the Responsible Adult for the client (if applicable) must agree to the following: Important, please read and sign below. • The information contained in this registration application and the medical document, or registration certificate as applicable, is correct and complete; • The applicant (client) is ordinarily a resident in Canada; • The medical document, or registration certificate as applicable, used for this application is not being used to seek or obtain cannabis from another source; • The original of the medical document is provided in support of this application; • The applicant (client) will use dried cannabis only for their own medical purposes; • The indications, safety and risks of cannabis use have not been adequately studied and the appropriate dosage is unclear. Client and caregiver (if applicable) acknowledge(s) that any medical cannabis product obtained from Aqualitas is used so at their own risk and release(s) Aqualitas, 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; • Client and Responsible Adult (if applicable) consent(s) to the health care practitioner named in their document disclosing required personal information to Aqualitas for the purposes of complying with the requirements of the Cannabis Act. and Regulations. Client and caregiver (if applicable) understand(s) and agree(s) that a copy of this consent and registration application, as well as information about the client's registration status and usage patterns may be provided to the health care practitioner named in their medical document; • Client and Responsible Adult (if applicable) consent (s)to Aqualitas' collection, use and disclosure of necessary personal information in order to process this registration, to provide products or services, to comply with the Cannabis Act and Regulations (including disclosure of personal information to provincial licensing authorities upon request), and otherwise in accordance with Aqualitas' Privacy Policy (https://aqualitas.ca/en/privacy-policy-3/). • By signing this registration form, client and Responsible Adult (if applicable) allow(s) Aqualitas to (a) send product and registration information to the physical and email addresses provided therein, and (b) communicate with them via email regarding registration status, product availability, order status, and other matters in accordance with Aqualitas' Privacy Policy (https://aqualitas.ca/en/privacypolicy-3/).

Discounts (if applicable)

New clients with Aqualitas will receive a 25% off welcome discount on their first order! Patients that renew their annual authorization with Aqualitas, receive a 25% renewal discount as well! (Stackable with other eligible discounts, once per year). Persons over the age of 60 qualify for a 10% senior discount (determined by date of birth in the Client Information section).

Veterans Affairs Canada (if applicable)

If you are a Canadian Veteran, we need you to fill out the information below to properly submit your request for authorization.

Responsible Adult Information (if applicable)

Responsible adult must fill out this section.

Health Care Practitioner Information (if applicable)

Must be completed by Health Care Practitioner who provided the medical document if they consent to receiving cannabis on behalf of the patient.

Compassionate Pricing (if applicable)

Aqualitas Inc. is proud to offer Compassionate Pricing to our clients who need financial assistance to obtain their medicine. Aqualitas Inc. offers a Compassionate Pricing Program for those living with an income under $30,000 per year. Under the Compassionate Pricing Program, eligible clients receive a 25% discount on all cannabis products. To qualify, all you need to do is submit one of the following with your registration: a) proof of receipt of financial assistance from either a federal or provincial program, or b) a copy of your 'Notice of Assessment' from the Canada Revenue Agency indicating your income falls below $30,000. Once received, Aqualitas will review your request for inclusion in the Aqualitas Compassionate Pricing Program. Clients must confirm their eligibility on an annual basis when new Medical Documents are submitted and Client Registration is either confirmed or denied. Aqualitas reserves the right to request documentation of eligibility. If such proof cannot be provided on request then Aqualitas has the right to cancel your participation in ourCompassionate Pricing Program. All information obtained will remain confidential and only the Client Care and Accounting department will have access to it. Aqualitas retains the right to verify this information periodically and reassess the situation accordingly. For more information on this program, please contact our Client Services Team by toll-free telephone, at 1-833-300-AQUA (2782), or by email at clientsupport@aqualitas.ca