ZYUS - Patient Registration

Given Name:

Given name is required

Surname:

Surname is required

Date of Birth:

Please provide valid (MM/DD/YYYY) date of birth

Gender:

Email:

Valid email is required

Telephone:

Invalid phone #, format should be 1(xxx)xxx-xxxx

Canadian Veteran

Veteran's Blue Cross Number:

Invalid number

Type of Registration:

Required

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When applicable, make sure to include complete Civic/Street address, SITE, COMP, PO BOX, RR, GD and STN/RPO.

See Canada Post Addressing Guidelines for more information.

Physical Address

Address Line 1:

Address is required

Address Line 2:

Address is required

City:

City is required

Province:

A choice is required

Postal Code:

Valid postal code is required, 6 characters with following pattern "A9A9A9"

Mailing Address

Same As Physical

Address Line 1:

Address is required

Address Line 2:

City:

City is required

Province:

A choice is required

Postal Code:

Valid postal code is required, 6 characters with following pattern "A9A9A9"

Shipping Address

Same As Physical

Address Line 1:

Address is required

Address Line 2:

City:

City is required

Province:

A choice is required

Postal Code:

Valid postal code is required, 6 characters with following pattern "A9A9A9"

I have requested that medical cannabis products be delivered to my healthcare practitioner's office, with their consent noted on the medical document.

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A caregiver is a designated person who is responsible for the patient and/or applying on behalf of the patient.

Important: caregiver must be physically present to complete registration.

Primary Caregiver

Given Name:

Given name is required

Surname:

Surname is required

Date of Birth:

Please provide valid (MM/DD/YYYY) date of birth

Gender:

Relationship to the Patient:

Required

Email:

Valid email or phone is required

Telephone:

Valid phone or email is required, format should be 1(xxx)xxx-xxxx

Caregiver #2

Given Name:

Given name is required

Surname:

Surname is required

Date of Birth:

Please provide valid (MM/DD/YYYY) date of birth

Gender:

Relationship to the Patient:

Required

Email:

Valid email or phone is required

Telephone:

Valid phone or email is required, format should be 1(xxx)xxx-xxxx

Caregiver #3

Given Name:

Given name is required

Surname:

Surname is required

Date of Birth:

Please provide valid (MM/DD/YYYY) date of birth

Gender:

Relationship to the Patient:

Required

Email:

Valid email or phone is required

Telephone:

Valid phone or email is required, format should be 1(xxx)xxx-xxxx

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If you have your medical document on hand, please upload it now. You may still continue with the application online, however, ensure your health care practitioner faxes your medical document to toll free: 1-877-226-5909. Alternatively email to care@zyus.com

If you have a scan of your veterans Blue Cross card or any other relevant documents you may upload now.

Medical Document

Drop a file here to upload it, or Click To Browse. Supports PNG, JPG, and PDF

Veteran's Blue Cross Card

Drop a file here to upload it, or Click To Browse. Supports PNG, JPG, and PDF

Additional Documents

Drop a file here to upload it, or Click To Browse. Supports PNG, JPG, and PDF

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The applicant acknowledges that cannabinoids have not been 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.
The applicant acknowledges and agrees that he or she is using any cannabinoid product obtained from ZYUS Life Sciences Inc.(ZYUS) at his or her own risk and releases ZYUS, its affiliates, 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 cannabinoids obtained from ZYUS.
The applicant ordinarily resides in Canada.
The information in this application and medical document or registration certificate is correct and complete.
The medical document has not, to the knowledge of the applicant been altered.
The medical document is not being used to seek or obtain cannabinoids from another source.
The applicant intends to use any cannabinoid products supplied to them on the basis of this application only for their own medical purposes.
The applicant consents to ZYUS’ collection, use and disclosure of personal information contained in this patient registration form, medical document or registration certificate (if applicable), in order to complete registration of the applicant and communicate with the healthcare practitioner named in the medical document, licensing authorities and ZYUS’ service providers, in accordance with ZYUS’ privacy policy and applicable laws.
If the applicant has a specified K number on this application, the applicant consents to ZYUS sharing personal details and information contained in this application with Veterans Affairs Canada or the applicant’s insurance provider.
The applicant consents and permits ZYUS to send product and registration information to the physical addresses identified in the patient registration form, and communicate with the applicant via email regarding registration status, product availability, order status, and other matters in accordance with ZYUS’ privacy policy.

I consent to receiving updates from ZYUS regarding clinical trials, news and educational material. I understand that I may withdraw my consent at any time.

By checking this box, you agree to the terms outlined above and confirm that the information you have provided is correct to your knowledge.

Signer For Patient:

Required

Patient Signature:

Valid signature required

Sign with finger or mouse above

I, , acknowledge that I am the caregiver for and take responsibility for the ordering, safe storage and administration of medical cannabis products.

Sign with finger or mouse above

Valid signature required

I, , acknowledge that I am the caregiver for and take responsibility for the ordering, safe storage and administration of medical cannabis products.

Sign with finger or mouse above

Valid signature required

I, , acknowledge that I am the caregiver for and take responsibility for the ordering, safe storage and administration of medical cannabis products

Sign with finger or mouse above

Valid signature required

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A ZYUS team member will be in contact with you at .

An email has been sent to . Please follow the instructions in the email to complete your registration.

Registration: 3 Easy Steps

It can be challenging to find the best therapeutic option for you. Whether this involves experiencing symptoms or suffering from side effects from current treatments, it can be difficult to get through the day, let alone engage in day-to-day activities. We encourage patients and healthcare practitioners to work together and discuss the benefits and risks of cannabinoids to determine the ZYUS formulations best suited for patient needs.

To ensure cannabinoids are easily accessible, we strive to make the registration process as simple and comprehensive as possible

Complete Medical Document

A healthcare practitioner is required to complete a Medical Document on behalf of the patient. Schedule a free online consultation with a licensed healthcare practitioner or download the Medical Document to bring to your healthcare practitioner.

Complete Patient Application

Complete the application to register online or complete the downloadable Application (PDF). If you currently reside in a hostel, shelter, hospice or similar institution please download and use PDF application.

Confirmation of Registration

Patients will receive an email that confirms their registration. This email will also introduce patients to the ZYUS Patient Care Centre and provide instructions about how to log in and order their authorized formulations.

Application

First time patients - Complete the application document online or complete the downloadable Application (PDF) if you currently reside in a hostel, shelter, hospice or similar institution.

Returning or Renewal Patients - Please log in to your account for your easy renewal and as always you can contact patient care, we're here to help!

Schedule a free online consultation with a healthcare practitioner, to determine if cannabinoids are an option for you.

Get Started The telehealth platform will open in a new tab. or Download PDF Medical Document PDF is fillable and can be sent via email or printed

Once a healthcare practitioner has completed your Medical Document, register online to complete the Patient Application.

Please contact our Patient Care Team with any question or concerns. We're here to help.

If you choose to complete the downloadable forms, here is how to send the documents to ZYUS:

Secure fax: 1-877-226-5909
Email: care@zyus.com
Registered Mail:
ZYUS
Patient Care
204 - 407 Downey Road
Saskatoon, SK S7N 4L8

Please be advised we only accept original documents, not photocopies or scanned copies if sending via registered mail

Registration Changes and Updates

Patients may use the Application to Amend Registration Form to update and make changes to the original application.

Registration Renewal

Returning or renewing your registration with ZYUS - Please log in to your existing account for quick renewal and ensure to visit with your health care provider to submit a new medical document.

Patient Information

Patient Contact Information

Responsible Person / Caregiver Information (If Applicable)

Documents

Declaration of the Applicant (or Person Responsible for the Applicant)

Registration Complete

Ways To Register

Registration: 3 Easy Steps

Application

Registration Changes and Updates

Registration Renewal