*indicates mandatory fields

Patient Details

Gender*

Billing Address

Is billing address same as shipping address?

Shipping Address

Are You A Veteran?*

Are You A Senior? (Age 65+)

Are You A First Responder?

Are You Eligible for Compassionate Care Pricing?

Are you applying with a registration certificate issued by the minister of health?*

Note: This is different from our standard registration process and will not apply to most patients, if you're unsure select 'no'.

Patient Digital Signature

If you require any assistance to register, please call us at 1-844-976-5223 and we will take care of it for you.