London Cannabis Compassion Center Lynn Harichy 199 Wellington St. London, ON N6B 2K9 519-474-3943

Membership Form (Please print) _________________________ _________________________ _____ Surname First Name Middle Initial ___/___/___ ___ Date of Birth (YY/MM/DD) Sex _________________________ ____________________ _____ ___________ Street Address City Prov Postal Code (___) _____-_______ (___) _____-_______ Home Phone Number Business Phone Number ________________________________________ (___) _____-_______ Emergency Contact Name #1 Phone Number ________________________________________ (___) _____-_______ Emergency Contact Name #2 Phone Number ________________________________________ (___) _____-_______ Physician's Name Physician's Phone Number _________________________ ____________________ _____ ___________ Physician's Street Address City Prov Postal Code

Share information about the Medical Condition for which you need our services and details of your health, such as allergies, medications, or special needs. Please feel free to write a bit, on a separate sheet of paper, about any negative experiences you've had treating your condition (side effects, dependence, etc.) and any experiences you've had, or opinions you have about medical marijuana.

L.C.C.C. Staff Use Only Application #: _______________ Approval Information: ________________________________________________ Staff Signature: _______________

Category Specifications  |  Category One Form  |  Category Two Form  |  mharichy@worlddrive.com