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Why Grow?
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Why Use Us
How It Works
Prices
FAQs
Contact
Why Grow?
GET STARTED NOW
Patient Intake Form
Step 1 of 3
0%
$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
*
Month
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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
Alberta
British Columbia
Manitoba
New Brunswick
Newfoundland and Labrador
Northwest Territories
Nova Scotia
Nunavut
Ontario
Prince Edward Island
Quebec
Saskatchewan
Yukon
Province
Postal Code
Is The Above Address Your Mailing Address?
*
Yes
No
Mailing Address
Street Address
Address Line 2
City
Alberta
British Columbia
Manitoba
New Brunswick
Newfoundland and Labrador
Northwest Territories
Nova Scotia
Nunavut
Ontario
Prince Edward Island
Quebec
Saskatchewan
Yukon
Province
Postal Code
Gender
*
Male
Female
Are you Pregnant or nursing?
*
Yes
No
Grams Per Day
*
Select
5 grams per day (25 Indoor plants, or 10 Outdoor plants)
10 grams per day (49 Indoor plants, or 19 Outdoor plants)
20 grams per day (98 Indoor plants, or 38 Outdoor plants)
30 grams per day (146 Indoor plants, or 57 Outdoor plants)
40 grams per day (195 plants indoors or 76 Outdoor plants)
50 grams per day (244 Indoor plants, or 95 Outdoor plants) <- Most Popular
60 grams per day (292 Indoor plants, or 114 Outdoor plants)
70 grams per day (341 Indoor plants, or 133 Outdoor plants)
80 grams per day (390 Indoor plants, or 152 Outdoor plants)
95 grams per day (463 Indoor plants, or 181 Outdoor plants)
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?
*
Select
Less than 1 year
1-2 years
3-5 years
6-10 years
10-20 years
20-35 years
35+ years
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