Intake Form - Canna Causes Foundation

CannaCauses Foundation

Cannabis Therapy™ Consultation Request

“Everyone deserves the medicine they need”

"*" indicates required fields

Step 1 of 5

Full Name*

Phone*

Email*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Gender*

Male

Female

Prefer Not To Answer

Preferred Contact Method (Check All That Apply)*

Phone

Text

Disability: Can you walk or are you wheelchair bound?*

Please Upload A Photo of A Valid ID/Driver License*

Max. file size: 50 MB.

Physicians Name*

Physicians Phone Number*

Primary Diagnosis*

Multiple Sclerosis

Parkinsons

Cancer

Chronic Pain

PTSD

Depression

Anxiety

Arthritis

Other

What Type Of Multiple Sclerosis*

Please Specify Stage Of Parkinson's*

What Stage Of Cancer*

What Type Of Cancer*

What Stage Of Chronic Pain

What Type Of Chronic Pain*

What Stage Of PTSD

What Type Of PTSD*

What Stage Of Depression

What Type Of Depression*

What Stage Of Anxiety

What Type Of Anxiety*

What Stage Of Arthritis

What Type Of Arthritis*

Please Specify Other Diagnoses*

What Stage

What Type

Date of Diagnosis*

Age*

Height*

Weight*

Please enter a number from 1 to 1000.

Are You The Caregiver, Spouse, or Parent?*

Relationship*

Caregiver Email*

Caregiver Phone Number*

Is your caregiver your Point of Contact?*

Primary Language*

Please Type In Your Language*

Has your doctor ever taken you off of any of your meds for any period of time? Or have you been on them consistently?*

Which medication and for what reason?*

Product Name

Total

Consent*

I agree to the privacy policy.

Once your intake form is complete, click the blue "Add to Cart" button
Proceed to your cart to submit your form and payment. (Note: Click the cart icon at the top right corner of webpage)
Once your payment is submitted you will receive a confirmation email to set you up for a Consultation with Aryn Sieber.

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