Are you a Canadian resident? (required)
Are you at least 18 years of age? (required)
Are you a Military Veteran?
Do you suffer from any of the following medical conditions?
ADDADHDAnxietyArthritisAsthmaAutismBrain InjuryCancerChronic NauseaChronic PainCrohn's DiseaseDegenerative DiseasesDepressionEpilepsyFibromyalgiaGlaucomaHepatitis CHIV/AIDSInsomniaIrritable Bowel SyndromeMSPanic AttacksParkinson's DiseasePTSDSeizure DisordersSleep DisordersOther (fill in box below)
Do you have any of the following medical documents?
Letter of DiagnosisX-RayMRISympton-Ailment ReportPrevious Prescription for Medical CannabisPrevious Prescription for Current AilmentRecord of Previous Doctors VisitOther (fill in box below)
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