Registration and Renewal Forms

Medical Document

To be filled out by your health care practitioner.

Medical Client Registration

For applicants with a permanent address.

Expanded Medical Client Registration

For applicants who do not have a permanent address (applicant currently resides in a shelter, hostel, or similar institution.)
For 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.

Amendment Forms


Changes to your residential, mailing, or shipping address.

Name/Date of Birth

Changes to your name or date of birth.

Responsible Individual(s)

Changes to your Responsible Individual(s).

Non-Residential Address

Changes to a non-residential address (a shelter, hostel, or similar institution).

Physician Address

If you have your product shipped to your health care practitioner, and your practitioner has had a change of address

Phone number and/or Email address

Changes to your phone number or email address. 

Paper forms can be sent to Broken Coast at: 3695 Drinkwater Rd. Duncan, BC V9L 0E9

Thank you for visiting Broken Coast!
Before entering our site, whether you are just stopping by or are a longtime client, we kindly ask that you verify your date of birth and province.