Your Name *

First Name

Last Name

Your Phone Number *

Country

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Patient's Name

If different from above

First Name

Last Name

Patient's Date of Birth *

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DD

YYYY

Patient's Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Select what best describes the address you provided

Private residence

Long-term care residence / nursing home

Hospice

Other (please state below)

OHIP Card Expiry Date

MM

DD

YYYY

Reason for seeking treatment *

Please check all that apply

Anxiety

ADHD

Autism Spectrum Disorder

Appetite Stimulation

Arthritis

Back Pain

Cancer

Chronic Pain

Colitis

Crohn's Disease

Dementia

Dermatological Condition (please indicate below)

Fibromyalgia

Head and/or brain injury

Irritable Bowel Syndrome

Multiple Sclerosis

Nausea

Parkinson's Disease

Other Neurodevelopmental Disease (please indicate below)

Post Traumatic Stress Disorder

Sleep Disorder

Other (please specify)

Medical History *

Check all that apply

History of schizophrenia (personally or immediate family)

Pregnant/breastfeeding/planning to become pregnant

History or current use of cannabis

Younger than 25 years old

None of the above