Important Forms

1) Need to renew your forms with Broken Coast?

MEDICAL DOCUMENT

FORM A (Online) - Applicants with a permanent address
FORM A (PDF) - Applicants with a permanent address

FORM B - Applicants who do not have a permanent address (Applicant currently resides in a shelter, hostel, or similar institution.)

FORM C - Applicants with a permanent residential address and (a) responsible individual(s) and/or (b) who are having their product shipped to their health care practitioner.

 2) Need to amend information on your registration document?

Contact Us

Questions? Comments? Contact us using the form below:

Submit

You can also contact us by telephone at 1-888-486-7579, or by email at info@brokencoast.ca.

Our office hours are from 8 a.m. to 4 p.m. PST, Monday to Friday.

Mailing Address: Box 1150
Ladysmith, BC, V9G1A8

 

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