Please fax this completed document to: 1-844-427-4796or scan and email to: info@aphria.com

Mail original document to:Aphria Inc. PO Box 20009 269 Erie St SouthLeamington ON Canada N8H 3C408.05.02 August 25, 2017

SIGNATURE

PATIENT INFORMATION

Given First Name Last Name D.O.B (MM/DD/YYYY)

Primary Phone Number

Male Female Patient ID Number

Organization (if not private) Address Buzzer Code or PO Box(if applicable)

Unit Number

By signing this document you state that you understand, agree, and consent to each of the following statements:1. You ordinarily reside in Canada2. The information in this application is correct and completeBy signing this Registration Amendment Document you consent to Aphria’s collection, use and disclosure of the personal information contained in it and in all related documents, such as any medical document or registration certificate, in accordance with Aphria’s External Privacy Policy available at: www.aphria.ca. This includes, without limitation, disclosure of the Patient Registration and related documents to the health care practitioner named in the patient’s Medical Document and to any clinic or employer with which the health care practitioner works. Hard copies of the External Privacy Policy are available upon request. If the personal information in the Patient Registration pertains to someone other than you, you represent and warrant that you have obtained their consent and/or have authority to consent on their behalf. Consent may be withdrawn at any time but such withdrawal will not have retroactive effect. NOTE: This may have implications to you and/or the subject individual and will not affect the collection, use and disclosure of personal information where such collection, use and disclosure is permitted or required by law without consent.

Patient/Caregiver Signature: Date (MM/DD/YYYY):

Current Last NameCurrent First Name

Please complete the form below if you, the patient, haverecently had a name(s) change or change in gender.

By checking this box, I agree to include on a separate sheet, the required documentation to validate my change of information above (i.e., Driver’s Licence, Health Card, Passport and/or Marriage certificate etc).

CHANGE OF CAREGIVER CHANGE OF PATIENT INFORMATION

Email

Male Female

I would like to add an additional caregiver to my account

I would like to remove my current caregiver and add a newcaregiver to my account

I would like to remove my current caregiver from my account

CHANGE OF ADDRESS (Shipping/Primary Residence)

Caregiver’s Last NameCaregiver’s First Name

Caregiver’s D.O.B(MM/DD/YYYY)

I,

, am the responsible caregiver

for

Full Name of Caregiver

Relationship to Patient (as required)

Name of Patient

Caregiver’s Gender

City Province Postal Code

EmailPhone Fax

Residence Type

*Shelter/Hostel

Private

Group/Other

Nursing Home

*Attestation of residence required if Shelter/Hostel is selected:

Phone Fax

Manager’s Email

Manager’s SignatureDate (MM/DD/YYYY)

Please check box and complete below if mailing address differs from the address above

Province

Address Unit # Buzzer Code or PO Box

City Postal Code

Please check here if you request to have your medication sent to your Health Care Practitioner’s address, with their consent, as listedon your Medical Document.

Mail original document to:Aphria Inc. PO Box 20009 269 Erie St SouthLeamington ON Canada N8H 3C4

Please fax this completed document to: 1-844-427-4796or scan and email to: info@aphria.com OR

08.05.03 November 6, 2017

REGISTRATION AMENDMENT FORMPlease check & complete the fields that apply

Any questions?Call us: 1-844-427-4742