Here are the required registration forms

All new clients must complete a Registration Form, Medical Document and Consent to Disclose. Please read the instructions below carefully. Be sure to download the appropriate client registration form if you choose not to register online.

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1(888) 64-PEACE (73223)

Client Registration Form A

The most commonly used registration form - This document is for those individuals who have a permanent residence to which their medicine will be delivered.

Client Registration Form B

For clients who do not have a permanent residence. (For example: if you live in a nursing home, shelter, hostel or other similar institution in Canada)

Client Registration Form C

For clients who would like their medicine delivered to their health care practitioner’s office. Your health care practitioner must first agree to receive medicine on your behalf.

The Medical Document

This document acts as your prescription. It must be completed, signed and dated by your health care practitioner. We must receive the original signed version either by mail or secure fax. Please print this form and take it with you when you go to see your doctor or clinic specialist.

Consent to Disclose

This form must also be taken to your practitioner or clinic specialist. To verify your Medical Document, we are required to contact your practitioner's office to confirm the details. In order to do this, we must have this form completed. A copy of this form is to be retained by your health care practitioner and a second copy must be sent to Peace Naturals by mail or secure fax.

Forms For Your Doctor

Click below to download both the Medical Document and the Consent to Disclose. Both documents are to be completed by your health care practitioner. Please be sure to take them with you to your appointment.

The Medical Document

This document acts as your prescription. It must be completed, signed and dated by your health care practitioner. We must receive the original signed version either by mail or secure fax. Please print this form and take it with you when you go to see your doctor or clinic specialist.

Consent to Disclose

This form must also be taken to your practitioner or clinic specialist. To verify your Medical Document, we are required to contact your practitioner's office to confirm the details. In order to do this, we must have this form completed. A copy of this form is to be retained by your health care practitioner and a second copy must be sent to Peace Naturals by mail or secure fax.

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Forms For Your Doctor

Click below to download both the Medical Document and the Consent to Disclose. Both documents are to be completed by your health care practitioner. Please be sure to take them with you to your appointment and that you mention that you are part of the Peace Naturals Share the Love Referral Program.

The Medical Document

This document acts as your prescription. It must be completed, signed and dated by your health care practitioner. We must receive the original signed version either by mail or secure fax. Please print this form and take it with you when you go to see your doctor or clinic specialist.

Consent to Disclose

This form must also be taken to your practitioner or clinic specialist. To verify your Medical Document, we are required to contact your practitioner's office to confirm the details. In order to do this, we must have this form completed. A copy of this form is to be retained by your health care practitioner and a second copy must be sent to Peace Naturals by mail or secure fax.