1. General ConsentBy signing this document, you state that you understand, agree, and consent to each of the following statements:
1.1. You ordinarily reside in Canada.
1.2. The information in this application and the accompanying Medical Document is correct and complete.
1.3. This Medical Document is not being used to seek or obtain cannabis from another source.
1.4. The use of dried cannabis and cannabis oil are for your own medical purposes ONLY.
1.5. The original medical document is provided in support of the application.
1.6. Medical cannabis is not currently approved for use as a pharmaceutical drug in Canada. You are using medical product obtained from Dykstra Greenhouses at your own risk. You hereby release Dykstra Greenhouses and its related entities from any and all actions, claims, complaints, demands for damages,
personal losses, and/or injuries arising directly and indirectly from the use of medical cannabis obtained from Dykstra Greenhouses.
2. Privacy Consent2.1. By signing this consent form, you acknowledge you will be a registered customer of Dykstra Greenhouses, a Licensed Producer under
the Cannabis Act, and its accompanying Regulations (the “Act”). 2.2. You acknowledge that medical cannabis is not approved for use as
a drug in Canada, that its indications, safety, and risks have not been adequately studied and the appropriate dosage is unclear. 2.3. You
acknowledge and agree that you are using any medical cannabis product obtained from Dykstra Greenhouses at your own risk, and
release Dykstra Greenhouses from any and all actions, claims, complaints and demands for damages, loss, liability or injury
whatsoever arising directly or indirectly as a consequence of the use of medical cannabis obtained from Dykstra Greenhouses.
2.4. Dykstra Greenhouses makes no representations and gives no warranties or conditions, whether express, implied, statutory, or otherwise, including, without limitation, any warranties or conditions of merchantability, merchantable quality, durability, or fitness
for a particular purpose, all of which are hereby disclaimed. That said, Dykstra Greenhouses takes its product quality very seriously, as well as its obligations under the Cannabis Act to investigate all customer complaints. If at any time you have an issue with your
Dykstra Greenhouses medicine, we encourage you to get in touch with us.
2.6. By signing this Registration Document, you consent to Dykstra Greenhouses collection,
use and disclosure of the personal information in accordance with Dykstra Greenhouses
related documents to the health care practitioner named in the client’s Medical
Document and to any clinic or employer with which the health care practitioner works.
2.7. If the personal information in the Client Registration Form pertains to someone other
than you, you represent and warrant that you have obtained their consent and/or have
authority to consent on their behalf. 2.8. Consent may be withdrawn at any time, but such
withdrawal will not have retroactive effect. NOTE: This may have implications to you
and/or the subject individual and will not affect the collection, use and disclosure of
personal information where such collection, use and disclosure of personal information
is permitted or required by law without consent.
By inserting my name below and clicking 'Register', I acknowledge that I am providing my digital signature and I confirm and acknowledge the boxes selected above.
Upload Medical Document and/or ACMPR License here
Email your medical document to email@example.com
Have your Medical Practitioner Fax your document to 905-682-2110
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