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PERSONAL INFORMATION
First Name *
Last Name *
Email Address
Password
Phone *
Birth Date *
Driver's License Number
Address
City
State
Zip Code
How did you hear about us?
How would you like to be contacted?
Would you like to receive specials via email?
Would you like to receive specials via text?
DOCTOR'S INFORMATION
Doctor's Name *
Doctor's Phone *
Dr. Verification Site
Recommendation Number
Recommendation Exp. Date
Dr's Recommendation
Drivers License Picture
Picture
Symptoms
Arthritis
Depression
Loss of Appetite
Other 		Cannabis Questions:
Currently using, or have in the past used cannabis: Yes No
Has cannabis helped to relieve your symptoms: Yes No
Preferred Strain: Indica Sativa Hybrid
Methods used to consume Cannabis:
Estimated cannabis use:
How long have you used cannabis:
Do you know how cannabis affects you? Yes No
Has the amount of cannabis needed to control your symptoms changed over time? Yes No
How has your cannabis consumption changed in the last six months: Changed No Change
What do you attribute the change to:
Have you ever stopped using cannabis and had your symptoms return or worsen? Yes No