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Medical Cannabis Pre-Qualification Form

There are two steps for the registration process. As the 1st STEP: PLEASE answer the following pre-qualification questions by completing the following form. We need to verify that you are a Canadian citizen of legal age, and you can check off any medical conditions that may apply in your particular case.

Upon submitting this you will automatically be directed to the next section. To complete the registration process, you will be asked to provide some additional details, and we will provide two options by which you can proceed . You could complete the Online Assessment Form, or alternatively we will provide details to contact a Customer Care Representative who can speak to you directly about your case.

Pre-Qualification for Medical Weed

Please Complete the Following Pre-Qualification Questions

Declaration

I declare my intention to use edibles is for the purpose to treat one or more medical conditions, and I invoke my right to medicate with products made with cannabis, under the Canadian Charter of Rights and Freedoms as outlined in the Supreme Court of Canada Decision in R. v. Smith. In addition I agree to handle such products responsibly and to keep all medications locked away from children and other persons.

YES

Acknowledgement

I acknowledge and agree that using any product obtained from, or as a result of direct referral from The Green Chef is at my own risk, and I release The Green Chef (and any of its affiliated partners or companies) from any and all actions, claims, complaints and demands for damages, loss or injury whatsoever arising directly or indirectly as a consequence of the use of medical cannabis products obtained.

YES

Confirm Personal Status

Are you a Canadian resident?

YesNo

Are you at least 19 years of age?

YesNo

Are you a Military Veteran?

YesNo

Do you have a valid provincial health card?

YesNo

Are you presently licensed to use Medical Cannabis?

YesNo

Do you suffer from any of the following medical conditions?

ADDChronic PainInsomniaADHDCrohn's DiseaseIrritable Bowel SyndromeAnxietyDegenerative DiseasesMSArthritisDepressionPanic AttacksAsthmaEpilepsyParkinson's DiseaseAutismFibromyalgiaPTSDBrain InjuryGlaucomaSeizure DisordersCancerHepatitis CSleep DisordersChronic NauseaHIV/AIDSOther (please specify)

Can you list any past or present medications and/or treatments?

Do you happen to have any of the following medical documents?

Letter of DiagnosisPrevious Prescription for Medical CannabisX-RayPrevious Prescription for Current AilmentMRIRecord of Previous Doctors VisitSympton-Ailment ReportNO or Other (fill in box below)

Please specify your primary interests

Access to EdiblesAccess to Medical FlowerAccess to Oils & ConcentratesGetting LicensedOther (please specify)

Please indicate your experience with using Cannabis

Regular TokerOnce in a whileOnly tried it a few timesNever tried beforeOther (please specify)

Please indicate your experience with consuming Edibles

Familiar taking EdiblesTried once, or few timesNever tried beforeOther (please specify)

Do you know your tolerance level for Edibles?

10-20mg40-60mg75-100mg150+I'm not sureOther (please specify)

Do you have experience with dispensaries?

Prefer buying from a dispensaryOK with dispensaries but prefer Health Canada regulated cannabisWill not buy from a dispensaryOther (fill in box below)

Contact Information

First Name

Last Name

City or Location

Telephone

Email

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