Store: 778-265-5250 | Mail Orders: 778-265-7400 info@pineapplevictoria.ca

Membership Application

 

Full Name
DOB (M/D/Y)
Email
Phone
Mailing Address
City
Postal Code
Identity Verification

Please upload a scanned image or photo of your government issued Photo ID. We accept driver's licence, Identity Card, health card or, passport.

List the conditions for which you use or wish to use cannabis
List the treatment you receive for your conditions
List all the allergies from which you suffer
How often do you use cannabis and how much do you consume?
Do you experience any negative/unpleasant effects when using cannabis? If so, explain
MEMBERSHIP AGREEMENT AND CODE OF CONDUCT

NO SELLING OR SHARING

Purchased cannabis and related products are for the member alone.

I agree to not give or share my purchased medication with anyone else, including minors.

BE RESPONSIBLE

Please use your medication in a responsible manner. Know your limits.

BE POLITE

Please be respectful to fellow members, staff and neighbours.

I agree to not smoke, consume or ingest cannabis or loiter in front of or near the dispensary.

Anyone who is intoxicated will be politely asked to leave.

IMPAIRMENT

Cannabis may potentially cause a temporary decrease in coordination, cognitive abilities and short-term memory loss.

I agree to not operate heavy machinery, drive, go swimming, and related risks if I have consumed cannabis in any form.

DRUG INTERACTIONS

Health Canada clinical trials and research into drug interactions with cannabis have not been fully conducted.

I agree to consult with my physician if I am unsure about using cannabis if this section applies to my condition.

ALCOHOL, TOBACCO AND DRUG INTERACTIONS

I agree that cannabis mixed with alcohol and/or tobacco may cause nausea and vomiting.

Limit or stop your intake of alcohol when using cannabis products.

IRRITATION

I agree that heavy smoking without harm reduction techniques may lead to respiratory irritation.

BLOOD PRESSURE

An initial increase in heart rate and/or blood pressure may be problematic for those with heart, respiratory, circulation and mental health conditions.

I agree to consult with my physician if I am unsure about using cannabis if this section applies to my condition.

WITHDRAWAL

I agree that there are no significant withdrawal effects when cannabis use is ceased or decreased, however minor restlessness, nausea and fatigue may be experienced. Symptom relief will also be decreased or cease. PINEAPPLE EXPRESS CANNABIS DISPENSARY MEMBERSHIP AGREEMENT AND CODE OF CONDUCT

CANNABIS AND CANADIAN LAW

It is illegal in Canada to possess, grow or distribute cannabis. Health Canada states that “lawful possession/production is limited to those with ATP/PUPL/DPPL licensing” (Health Canada DHP MMPR).

Know your rights and take precautions to avoid arrest, property seizure, imprisonment and criminal record.

ACKNOWLEDGEMENT

I have read this form and I agree to abide by the code of conduct and cautions listed above. I agree that this form is filled out completely and accurately to the best of my knowledge. I accept that PINEAPPLE EXPRESS makes no guarantees or medical claims, and I hereby agree for myself, my heirs and executors to waive any claims against PINEAPPLE EXPRESS and its shareholders.

VIOLATION OF THE CODE OF CONDUCT WILL RESULT IN TERMINATION OF MEMBERSHIP.

PINEAPPLE EXPRESS HAS THE RIGHT TO REVOKE ANY MEMBERSHIP AT ANY TIME.

I have read the Membership Agreement and Code of Conduct and I agree to abide by the terms and conditions listed above.
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