Name:                                                                                                  Phone:

Address:

Date of Birth:                                                                                        Sex:

Medical Condition:

Physician’s Name:                                                                                Phone:

Address:                                                                                               Fax:

How long have you been using Cannabis?

How do you prefer to ingest this medicine?

How much / how often do you use Cannabis?

Does this amount fulfill your medical needs?

How does Cannabis affect your condition?

Comments:

I verify that all information and medical documents regarding my condition submitted to

Signature:                                                                                             Date: