STEP 1: CREATE YOUR ACCOUNT
Prospective Patient Patient Caregiver Health Care Practitioner

Completing this process will allow you to gain full access to our website and learn more about MedReleaf in case you are considering becoming a registered patient.

Completing this process will allow you to gain full access to our website, learn more about MedReleaf and become a registered patient.

Completing this process will allow you to gain full access to our website, learn more about MedReleaf and register a patient under your care.

Completing this process will allow you to gain full access to our website and learn more about MedReleaf.

This is a required field.
Names must only contain letters.
Must be at least 2 characters.
This is a required field.
Names must only contain letters.
Must be at least 2 characters.
This is a required field.
Invalid email address
This is a required field.
Date must be in 'yyyy-mm-dd' format.
Email is in use.
This is a required field.
Password must be at least 8 characters.
Passwords do not match.
Please sign.

Required

I attest that I am responsible for the patient being registered below.

You must agree.

I acknowledge that I am interested in learning more and/or in becoming a registered patient for medical purposes. I have read, understand and agree to the terms and conditions and privacy policy.

I have read, understand and agree to the terms and conditions, applicant consent and privacy policy.

CREATE MY ACCOUNT
STEP 2: PATIENT DETAILS
Male Female Other
This is a required field.
Yes No

Primary Residence

Use this address as your billing address.
Residence Type:

If you are receiving food and lodging from a shelter, hostel or other non-residential location you must fill out form C and send it to us. Click HERE for the form.

This is a required field.
This is a required field.
Address must be longer than that.
This is a required field.
City must be longer than that.
This is a required field.
This is a required field.
e.g. L3R 6G4, L3R6G4
Postal Code is too long.

Billing Address

This is a required field.
Address must be longer than that.
This is a required field.
City must be longer than that.
This is a required field.
This is a required field.
e.g. L3R 6G4, L3R6G4
Postal Code is too long.
This is a required field.
e.g. 2893171000
Phone number is too long.
e.g. 2893171000, 289-317-1000
Phone number is too long.
This primary residence has no postal service.
CREATE MY ACCOUNT

Shipping Address

Applicable ONLY if your primary residence has no postal service.
This is a required field.
Address must be longer than that.
This is a required field.
City must be longer than that.
This is a required field.
This is a required field.
e.g. L3R 6G4, L3R6G4
Postal Code is too long.
CREATE MY ACCOUNT
STEP 2: ADDITIONAL CAREGIVER INFORMATION
This is a required field.
e.g. 2893171000
Phone number is too long.
Add Secondary Caregiver
Male Female Other
This is a required field.

Secondary Caregiver Information

Remove Secondary Caregiver
This is a required field.
Names must only contain letters.
Must be at least 2 characters.
This is a required field.
Names must only contain letters.
Must be at least 2 characters.
Invalid email address
This is a required field.
Date must be in 'yyyy-mm-dd' format.
This is a required field.
e.g. 2893171000
Phone number is too long.
Male Female Other
This is a required field.
Please sign.


Required

I attest that I am responsible for the patient being registered below.

You must agree.

I have read, understand and agree to the terms and conditions, applicant consent and privacy policy.

STEP 3: PATIENT INFORMATION
This is a required field.
Names must only contain letters.
Must be at least 2 characters.
This is a required field.
Names must only contain letters.
Must be at least 2 characters.
Invalid email address
This is a required field.
Date must be in 'yyyy-mm-dd' format.
Male Female Other
This is a required field.
Yes No

Primary Residence

Use this address as your billing address.
Residence Type:

If you are receiving food and lodging from a shelter, hostel or other non-residential location you must fill out form C and send it to us. Click HERE for the form.

This is a required field.
This is a required field.
Address must be longer than that.
This is a required field.
City must be longer than that.
This is a required field.
This is a required field.
e.g. L3R 6G4, L3R6G4
Postal Code is too long.

Billing Address

This is a required field.
Address must be longer than that.
This is a required field.
City must be longer than that.
This is a required field.
This is a required field.
e.g. L3R 6G4, L3R6G4
Postal Code is too long.
This is a required field.
e.g. 2893171000
Phone number is too long.
e.g. 2893171000, 289-317-1000
Phone number is too long.
This primary residence has no postal service.
CREATE MY ACCOUNT

Shipping Address

Applicable ONLY if your primary residence has no postal service.
This is a required field.
Address must be longer than that.
This is a required field.
City must be longer than that.
This is a required field.
This is a required field.
e.g. L3R 6G4, L3R6G4
Postal Code is too long.
CREATE MY ACCOUNT
STEP 2: DOCTOR DETAILS
This is a required field.
Specialization must be at least 4 characters.
License # can't be more than 25 characters.
This is a required field.

Clinic Address

This is a required field.
Address must be longer than that.
This is a required field.
City must be longer than that.
This is a required field.
This is a required field.
e.g. L3R 6G4, L3R6G4
Postal Code is too long.
This is a required field.
e.g. 2893171000
Phone number is too long.
e.g. 2893171000, 289-317-1000
Phone number is too long.
CREATE MY ACCOUNT
  1. Creating Account

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