PCC Form

Step 1 of 5

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1. Please Enter Your Information.(Required)

First Name Middle Initials Last Name

Date of Birth(Required)

MM slash DD slash YYYY

Gender(Required)

Female

Male

Marital Status(Required)

Single

Married

Domestic Partner

Separated

Divorced

Widowed

Address(Required)

Street Address Apt./Unit # City State ZIP Code

Mobile Phone(Required)

Email(Required)

How Did You Hear About Us?(Required)

Google/ Search Engine

Google/ Search engine

Social Media

Dispensary

Other

2. Please Select Your Condition(s) For Which You Seek Treatment With CBD or Medical Marijuana:(Required)

AIDS

Epilepsy or another Seizure Disorder

Pain or Chronic Pain

Tourette's Syndrome

Cancer

Hepatitis C

PTSD - Post-traumatic Stress Disorder

Cachexia

Cerebral Palsy

Obsessive Compulsive Disorder( OCD)

Muscular Dystrophy

Alzheimer's Disease

Glaucoma

Positive status for HIV

Ulcerative Colitis

Crohn's Disease

MS - Multiple Sclerosis

Spinal cord disease or injury

Nail Patella

Anxiety

Seizures

Nausea

CTE - Chronic Traumatic Encephalopathy

IBD - Inflammatory Bowel Disease

Sickle Cell Anemia

ALS - Amyotrophic Lateral Sclerosis

Fibromyalgia

Parkinson's Disease

Traumatic Brain Injury

Arthritis (all types)

Depression

Autism

Other

Other Conditions Not Listed

3. If This Is For A Child Under The Age Of 18 Are You The Responsible Parent Or Guardian?

Yes

4. Please Provide The Contact Information For The Parent or Guardian?(Required)

First Middle Last

Parent/ Guardians Relationship(Required)

Parent/Guardians Email(Required)

Parent/Guardians Contact Phone(Required)

5. Why Did You Book This Service?(Required)

Generally Interested in Cannabis

Want to know how to reduce side effects

Don't know what to purchase at the dispensary

Dosing Questions

Are Currently using cannabis and are seeking better results

Want to know what works best your condition

Other

List Other Reasons

6. Do Have Your Marijuana Card Already?(Required)

Yes

7. In What State Are You Registered As a Medical Marijuana Patient and Cardholder?(Required)

8. What Types of CBD Have You Tried In The Past?(Required)

Flower

Pre Rolls

Edibles

Tinctures

Gummies

Topicals

Vape

9. Have You Used Cannabis or Any Cannabis Products Before?(Required)

Yes

10. What Has Been or Is Your Preferred Method of Consumption?(Required)

Flower

Pre Rolls

Edibles

Tinctures

Gummies

Topicals

Vape

11. Have You Had Any Adverse Reactions or Negative Side Effects with Cannabis?(Required)

Yes

12. Could You Briefly Mention What Happened in Your Negative and or Adverse Reaction to Cannabis?(Required)

13. What Do You Hope To Achieve or Get From This Appointment?(Required)