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Patient Registration Form
Please note that the personal information provided on this Registration Form must match the information that appears on the Medical Document. For anyone completing this Registration Form on behalf of the Applicant, please select "Yes" on the "Are you the Applicant's Caregiver?" question and complete the section that follows. If you require assistance, contact our Client Care Team at 1-888-594-4272.
Personal Info
First Name
Last Name
Date of Birth
Gender
Your Email
Phone Number
Are you an existing JWC patient?
If you are an existing JWC patient transferring your medical document to our new company, Trichome JWC Acquisition Corp., please select 'No' to this question and complete a new registration.

Are you having your medical document transferred from an existing licensed producer?
Are you a veteran?
Primary Address
Street Address
Unit Number
City
Postal Code
Province
Is your shipping address different from your primary address?
Are you the Applicant's Caregiver?
Is this a private address?
Applicant Declaration
The following declaration should be signed either by the Applicant or the person responsible for the Applicant:
  • I hereby certify that the Applicant named herein is normally a resident in Canada.
  • I and/or the Applicant have read the “General Terms and Conditions” as published on the web site included in the “JWC Network” (as therein defined) which I agree to incorporate into this document by reference, and to which I acknowledge that I am bound.
  • I further certify that information given in this application and in any appended documents (i.e. proof of legal name change) is both correct and complete.
Name
Date