Get started

First name *

Last name *

Date of birth *

Postal Adress *

Phone *

Email *

What gender do you indentify as ? * What gender do you indentify as ? *FemaleMaleIntersexTransgenderNon-BinaryOther

If currently prescribed, who is your prescriber ? (say "none" if you don't have any prescriber) *

Have you seen a doctor for your condition ? * Have you seen a doctor for your condition ? *YesNo

What is your relationship to cannabis ? * What is your relationship to cannabis ? *I do not use cannabisI use cannabis oftenI occasionally use cannabisI am an existing medicinal cannabis patient with another clinic

Please select any conditions or secondary conditions you are suffering from, for which you are seeking treatment. (Choose as many as you like) * Please select any conditions or secondary conditions you are suffering from, for which you are seeking treatment. (Choose as many as you like) * Pain Addiction Anxiety Depression Muscle stiffness / Spasms Injury Eating Disorder Nausea and Vomiting (Chemo-induced, Non-chemo-induced) Loss of Appetite ADHD Autism Stress Glaucoma PTSD Emotional / Physical Distress Nightmares (PTSD) Emotional / Physical Distress (PTSD) Insomnia (Sleeping) Headaches Swelling

Select one of the following call back times and we will be in touch Select one of the following call back times and we will be in touchPlease call me back between 9am - 12pmPlease call me back between 12pm - 6pmPlease call me back between 6pm - 8pm