MedMe Request Form Instructions

MedMe Purchasing Contract

Section A

• Print your full name.
• Print your complete address starting with your house/apartment number, street, road, or avenue. Next put your city, province and postal code.
• Fill in your phone number including area code.
• Fill in your birth date starting with the day, then the month, then the year.
• Fill in your MMAR card number.  If you are presently applying for an MMAR card, write "in progress with Health Canada".
• Fill in amount of grams per day by dividing the maximum quantity at any time found on an MMAR card by 30.  If you are presently applying for an MMAR card, leave this line blank.
• Fill in the expiry date of your MMAR card starting with the day, then the month, then the year.   If you are presently applying for an MMAR card, leave this line blank.
• Fill in your requested strain.  If you are uncertain about your preferred strain, you can leave it blank, or call at 1 866 823 6521 for more information.
• Indicate whether you will be inhaling or orally taking your medication.

Section B

• Read over the contract content carefully.
• You will need to sign your name in full, print today's date
• Print your full name