Intake Form - ACMPR Direct

$397 flat fee for all licences up to 95 grams.
Step 1: Fill out your Patient Intake Form and Book Your Appointment (takes less than 10 minutes)

We need this information for our practitioners records. This is fully secure allows them to have your file ready and guarantees your grams per day you ask for. There’s no need to be anxious about these forms, just be honest and answer to best of your ability.
Name*
First Last
Your legal name is required for us to process your registration.
Date of Birth*
Phone*
Please do not include a “1” in front of the number.
Email*

What is your Skype ID or email you used to create your Skype account?
If you don't have an account please visit www.skype.com to register (phone or computer). For existing Skype users please add Skype username: Cannabis_Consulting
Click Here for help finding your Skype ID
Home Address*
Street Address Address Line 2 City Province Postal Code
Is The Above Address Your Mailing Address?*
- Yes
- No
Mailing Address
Street Address Address Line 2 City Province Postal Code
Gender*
- Male
- Female
Are you Pregnant or nursing?*
- Yes
- No
Grams Per Day*
Medical Condition & Symptoms
Condition(s) for which medical cannabis is being requested*
Check off symptoms associated with your primary condition. Select level of symptom severity. Level 1 - not severe, Level 5 - very severe
- Pain
Select Severity
- 1
- 2
- 3
- 4
- 5
Muscle Spasms
- Muscle Spasms
Select Severity
- 1
- 2
- 3
- 4
- 5
Mobility
- Mobility
Select Severity
- 1
- 2
- 3
- 4
- 5
Headache
- Headache
Select Severity
- 1
- 2
- 3
- 4
- 5
Seizures
- Seizures
Select Severity
- 1
- 2
- 3
- 4
- 5
Involuntary Movements
- Involuntary Movements
Select Severity
- 1
- 2
- 3
- 4
- 5
Anxiety
- Anxiety
Select Severity
- 1
- 2
- 3
- 4
- 5
Depression
- Depression
Select Severity
- 1
- 2
- 3
- 4
- 5
Concentration/Focus
- Concentration/Focus
Select Severity
- 1
- 2
- 3
- 4
- 5
Sleep Disturbance
- Sleep Disturbance
Select Severity
- 1
- 2
- 3
- 4
- 5
Visual Disturbance
- Visual Disturbance
Select Severity
- 1
- 2
- 3
- 4
- 5
Weight Loss
- Weight Loss
Select Severity
- 1
- 2
- 3
- 4
- 5
Lack of Appetite
- Lack of Appetite
Select Severity
- 1
- 2
- 3
- 4
- 5
Nausea/Vomiting
- Nausea/Vomiting
Select Severity
- 1
- 2
- 3
- 4
- 5
Low Energy
- Low Energy
Select Severity
- 1
- 2
- 3
- 4
- 5
Diarrhea
- Diarrhea
Select Severity
- 1
- 2
- 3
- 4
- 5
Constipation
- Constipation
Select Severity
- 1
- 2
- 3
- 4
- 5
What is your preferred method of taking cannabis?*
- Inhalation/Smoke
- Oral/Eat
- Topical/Cream
- Concentrates
- Juicing
- All of the above
What are your treatment goals?*
- Reduce Pain
- Improve Mood
- Improve Appetite
- Improve Daily Function
- Improve Sleep
- Other
How long have you been using cannabis?*
Have you ever experienced any negative side effects while using cannabis?*
- Yes
- No
If yes, please describe*
Step 2: Drug History and Pain Assessment

You are almost done! Just a few more questions and you can book your appointment.
Just answer the best you can.
Brief Drug History
In the past 12 months have you used any other drugs than cannabis?*
- Yes
- No
If yes, please describe*
In the past 12 months have you used drugs other than those required for medical reasons?*
- Yes
- No
If yes, please describe*
In the past 12 months have you abused prescription drugs?*
- Yes
- No
If yes, please describe*
In the past 12 months have you lost your job because of drug abuse?*
- Yes
- No
If yes, please describe*
In the past 12 months have you engaged in illegal activities in order to obtain drugs?*
- Yes
- No
If yes, please describe*
In the past 12 months have you been arrested for possession of illegal drugs?*
- Yes
- No
If yes, please describe*
In the past 12 months have you had medical problems as a result of your drug use (e.g. memory loss, hepatitis, convulsions, bleeding, etc.)?*
- Yes
- No
If yes, please describe*
Brief Pain Inventory
In the past 12 months have you used cannabis for pain?*
- Yes
- No
What treatments or medications are you receiving for your pain?*
In the past 12 months has pain interfered with any of the following activities (select all that apply)*
- General activity
- Mood
- Walking ability
- Enjoyment of life
- Appetite
- Normal work (includes both work outside the home and housework)
- Relations with other people
- Sleep Ability to concentrate

Step 3: Terms and Conditions
Please review the terms and conditions*
I agree to terms and conditions and I consent that I answered all the questions honestly.
Signature*
FileUpload a clear photo of your ID (drivers licence, health card, or passport)*
Patient Name*
First
Date Signed*
Date Format: MM slash DD slash YYYY

Patient Intake Form

Step 1 of 3

$397 flat fee for all licences up to 95 grams.

Step 1: Fill out your Patient Intake Form and Book Your Appointment (takes less than 10 minutes)

Medical Condition & Symptoms

Step 2: Drug History and Pain Assessment

Brief Drug History

Brief Pain Inventory

Step 3: Terms and Conditions

Created by growers for growers – we understand your needs – and are here to help you – we are available 24 hours a day, 7 days a week to answer your questions.