ECO Patient Registration

HOW TO BECOME A PATIENT

Have your physician or health care practitioner complete a medical document and have their office fax it to us.

The documentation should be faxed directly to our secure fax line at +1 833 523 2406.

Complete our registration form below or download and print the form and return to us by mail or email to clientcare@ecocanadianorganic.com

If you’d like help completing your registration, don’t hesitate to call us and we will be happy to walk you through the process.

Once we have received your medical document and registration form, we will verify your information and send you a registration confirmation by email. Your confirmation email will include your Client ID number and log in details.

Shop for your products with your Client ID and login details online (coming soon), or you can order medical cannabis by calling us at +1-506-523-9474.

ONLINE REGISTRATION FORM


All fields are required unless otherwise indicated.

This form must be completed by the client (if applying on their own behalf) or by a caregiver (someone responsible for the client) submitting the application on their behalf.

Once the required fields are filled, your personal email client (Gmail, Outlook, Hotmail, etc.) will automatically open with the completed registration form pre-filled. Simply review and send the email to complete your registration. This process ensures your data remains protected and secure.

Client Information

Residence Address

Mailing Address (if different from above residence address)

Shipping Preferences

If you would like ECO to ship product to an address other than the Residence Address provided above, please check the option that applies:

Veterans Affairs Canada

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

Health Care Practitioner Information

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

Shipping Address

Where you would like your product to arrive, if different from business address or consultation address provided on medical document.

Notice to the Health Care Practitioner: If the health care practitioner ceases to consent and receive cannabis for the client, the practitioner must send a written notice to that effect to the client and to ECO.

Upload Documents

Agreement

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 ECO is used so at their own risk and release(s) ECO, 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 ECO 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 ECO's 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 ECO Privacy Policy (https://ecocnb.com). By signing this registration form, client and Responsible Adult (if applicable) allow(s) ECO to (a) send product and registration information to the physical and email addresses provided therein, and (b) communicate with them via email (https://ecocanadianorganic.com).