Form - cannabis

50%

*
First Name Last Name
DOB*
Phone Number*
Address
City
Postal Code
Health card
(please include two letters if you have the green card)
Email*
SKYPE name
(if seeing the physician through telemedicine)
I understand that CannabisAdvocates.ca does not replace my family doctor.
(initial)
Medical Marijuana Consultation is a thorough medical history consult regarding symptoms and diagnosis where Cannabis would be an appropriate medicine. One Medical Document will be completed annually. Additional forms, including OSDP, and insurance will require a fee.

By signing this contract you are agreeing to the terms outlined above.
Signature*
Date

INTAKE FORM 2nd Page