STEP 1: CREATE YOUR ACCOUNT
Patient Caregiver Health Care Practitioner

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

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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