Appointment request

Which service are you applying for? *
I would like to obtain a prescription and a personalized treatment plan to purchase my medical cannabis from a vendor authorized by Health Canada.I would like to obtain a personal cultivation prescription to grow my own medical cannabis plans.

Do you have a family doctor? *
YesNo

Are you a veteran of the Canadian Armed Forces or the Royal Canadian Mounted Police? *
YesNo

Are you currently on a CNESST coverage program? *
YesNo

Are you currently on a coverage program with IVAC? *
YesNo

Personal information

Genre * ManWomanOther

First name *

Last name *

Date of birth *

Email *

Phone number *

Address *

City *

Province *

Postal code *

Medicare number (RAMQ) *

Expiration date *

Province issuing health insurance card *

Medical information

List the main medical diagnoses for which you wish to use cannabis : *

Other important medical information

Do you suffer from heart disease? *
YesNo

Do you suffer from schizophrenia? *
YesNo

Do you have a history of psychosis? *
YesNo

Are you currently pregnant, breastfeeding, or planning an upcoming pregnancy? *
YesNo

Do you suffer from bipolar disorder? *
YesNo

Are you currently taking anticoagulant medication? *
YesNo

Do you suffer from liver problems? *
YesNo

Do you suffer from high pressure? *
YesNo

Are you currently undergoing immunotherapy or have you received such treatment in the last 6 months? *
YesNo

Experience with cannabis

Check the box that best corresponds *
NoneI've had a prescription for medical cannabis in the pastFamiliar with recreational cannabisExperienced with recreational cannabis

Consent

I, the undersigned, , declare that I have read the general conditions of use of the appointment request and of the services of Solution Cannabis Médical, and that I accept them without reservation. I also agree to provide my personal information, including my first name, last name, and date, in order to benefit from the services offered by Solution Cannabis Médical. Date .

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