Your Name Name
First Last
Name of the person for the FREE one
First Last
For the 2 for 1 deal, you need to add here the name of the person. If you have no one for this deal as yet, you can email us later to tell us who to get it.
What is your mailing address?*
Street Address Address Line 2 City Province Postal Code
Your Current Address*
Street Address Address Line 2 City Province Postal Code
How many plants are you hoping to obtain? (grams per day):*
Email
Phone
What is your birth date?*

DD
MM
YYYY

Please note you must be 21 years or older for us to give you a prescription.
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).
Is the address above the same as your mailing address?*
How did you hear about us?*

Chief problem(s) for which medical cannabis is being requested:*
List all your current medications including dosage:*
List any medications you are allergic to:*
Do you use cocaine or other “street” drugs?*
Please list any street drugs do you currently use and how often you use them:*
Do any of your medications contain opiates? (Codeine, Morphine, etc.):*
Do you currently use cannabis for relief?:*
Please check all that apply:
- vapor
- edible
- topical
- smoke
Please list desired number of grams per day:*
How often do you use cannabis?:*
How often do you intake cannabis?:*
Have you ever experienced an unpleasant /unwanted side effect of marijuana?:*
Please describe your side effect:*
Are you aware of the possible side effects that may occur from use of marijuana?:*

Throughout our lives, most of us have had pain from time to time (such as minor headaches, sprains and toothaches). Have you had pain other than these everyday kinds of pain today?*
Which area do you feel pain the most?*
Please rate your pain by checking the one number that best describes your pain at its worst in the past 24 hours:*
Please rate your pain by checking the one number that best describes your pain on average:*
Please rate your pain by checking the one number that best describes how much pain you have right now:*
In the past 24 hours how much has pain interfered with your general activity?*
In the past 24 hours how much has pain interfered with your mood?*
In the past 24 hours how much has pain interfered with your walking ability?*
In the past 24 hours how much has pain interfered with your relationships with other people?*
In the past 24 hours how much has pain interfered with your sleep?*
In the past 24 hours how much has pain interfered with your enjoyment of life?*
In the past 24 hours how much has pain interfered with your ability to concentrate?*
In the past 24 hours how much has pain interfered with your appetite?*
Does the painful area change colour (perhaps mottled or red) when the pain is particularly bad?*
- Yes
- No
Does your pain make the affected skin abnormally sensitive to the touch?*
- Yes
- No
Does your pain come on suddenly and in bursts for no apparent reason when you are completely still?*
- Yes
- No

I get very frightened or have panicked feelings for apparently no reason at all:
Gently press on the painful area with your fingertip then gently press in the same way to a non painful area. How does this feel in the painful area?*
- No difference
- Discomfort – pins and needles, tingling or burning in the painful area
I feel miserable and sad:
I have lost interest in things:
I have a good appetite:
I feel scared or frightened:
I feel life is not worth living:
I still enjoy the things I used to:
I am restless and can't keep still:
I am more irritable than usual:
Worrying thoughts constantly go through my mind:
Upload a clear photo of your drivers licence or any form of ID*
Please review our terms and conditions:*
- I agree to the Terms and Conditions