About Applicant's Caregiver 1 Name of Applicant:

of 1

SURNAME, GIVEN NAME

Date of Birth of Applicant:

YYYY/MM/DD

Caregiver Information To be filled out if the applicant has one or more caregiver(s) who is/are responsible for the applicant. I agree to receive Hydropothecary's newsletter containing news, updates and promotions regarding Hydropothecary's products. You can withdraw your consent at any time.

Caregiver Name: Caregiver Date of Birth:

SURNAME, GIVEN NAME

Gender:

YYYY/MM/DD

M

F

Other:

Caregiver Email: Caregiver Phone Number:

OPTIONAL

Alternate Phone Number:

OPTIONAL

Statement CAREGIVER NAME I

Voicemail messages may be left at this number

am responsible for

APPLICANT NAME

Caregiver Signature:

X

Date:

YYYY/MM/DD

Alternate Caregiver Information

To be filled out if the applicant has more than one caregiver.

I agree to receive Hydropothecary's newsletter containing news, updates and promotions regarding Hydropothecary's products. You can withdraw your consent at any time.

Alt. Caregiver Name: Alt. Caregiver Date of Birth:

SURNAME, GIVEN NAME YYYY/MM/DD

Gender:

M

F

Other:

Alt. Caregiver Email: Alt. Caregiver Phone Number:

OPTIONAL

Alternate Phone Number:

OPTIONAL

Alternate Caregiver Statement CAREGIVER NAME I am responsible for

Voicemail messages may be left at this number

PATIENTS NAME

Alternate Caregiver Signature:

X

1-844-406-1852

Date:

120 Chemin de la Rive, Gatineau, QC, J8M 1V2

YYYY/MM/DD

hydropothecary.com

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