Pre-register

PERSONAL INFORMATION
Name *
Email Address *
Password *
Phone *
Birth Date *
Driver's License *
Address *
City *
State *
Zip Code *
How did you hear about us? *
How would you like to be contacted? *
DOCTOR'S INFORMATION
Doctor's Name *
Doctor's Phone *
Dr. Verification Site *
Recommendation Number *
Recommendation Exp. Date *
Completed Membership Form *
Dr's Recommendation *
Drivers License *
Picture *
Symptoms
Arthritis
Depression
Loss of Appetite
Other
Medical Cannabis Questions:
Currently using, or have in the past used cannabis: Yes No
Has medical 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