Register

Welcome! Please specify whether you are a patient or caregiver, then fill out the form below to register. *

I am a patient

I am a caregiver

Caregiver Information

First Name *

Middle Name *

Last Name *

DOB *

Gender *

Male

Female

Mobile Number*

Email *

Caregiver Residing Address

Address 1 *

Address 2 (Apt, Ste #)

City *

Province *

Postal Code *

Do you reside at the same address as the patient? *

Yes

Patient Information

First Name *

Middle Name

Last Name *

DOB *

Gender *

Male

Female

Phone Number *

Email *

K Number (Veterans Only)

Residing Address

Address 1 *

Address 2 (Apt, Ste #)

City *

Province *

Postal Code *

Shipping Address

Is your shipping address the same as your residing address? *

Yes

Patient Residing Address

Shipping Address

Address 1 *

Address 2 (Apt, Ste #)

City *

Province *

Postal Code *

Is this shipping address a private residence? *

Yes

Establishment Name *

By submitting this form, the applicant confirms that: -The applicant ordinarily resides in Canada. -This information in the application is correct and complete. -The medical document that forms the basis for the registration has not/is not altered. -The medical document is not being used to seek or obtain cannabis from another source. -The cannabis is being used for the applicants own personal medical purposes. -If an adult is signing on behalf of another person, they are responsible for the applicant. I have read the above statement and consent

Signature

Date (MM/DD/YYYY)

Welcome to Ütndr Medical’s Patient Registration

Step 1. Account Creation

Step 2. Get Your Medical Cannabis Card

Step 1. Account Creation

Patient Registration

Caregiver Information

Caregiver Residing Address

Patient Information

Residing Address

Shipping Address

Shipping Address

Signature

All Set

Step 2. Medical Cannabis Card

Ütndr Medical