Sign Up with Broken Coast
Use the form on this page to create an account with us. Once you've logged in you'll be able to view more details about our products.
Download a Medical Document from Broken Coast Cannabis HERE. This document must be filled out completely and signed by your health care practitioner.
Complete Application Form
Print and fill out the application form below that corresponds to your current living situation.
FORM A (Online)
FORM C - Applicants with a permanent address who have a caregiver or have their medicine sent to their doctor
Mail Forms to Broken Coast
Mail your paperwork to us. We require:
*Please send via Canada Post. Couriers such as FedEx and UPS cannot deliver to PO boxes.
Questions? Comments? Contact us using the form below:
You can also contact us by telephone at 1-888-486-7579, or by email at firstname.lastname@example.org.
Our office hours are from 8 a.m. to 4 p.m. PST, Monday to Friday.
Mailing Address: Box 1150
Ladysmith, BC, V9G1A8