Copy of Consultation Form

The journey to your holistic healing is just a step away. Fill in the details below and we’ll get you in touch with one of our experts. (All details filled are confidential)

• Name *
• Email *
• Phone *
• Date of Birth *
• Address *
• City *
• State / Province / Region
• Zip / Postal Code
• Weight
• Do you have or are you currently taking any medications for:

  None

  Schizophrenia

  Heart Disease

  High/Low Blood Pressure

  Mental Disorder

• Do you have a family history of Schizophrenia or mental illness?

  Yes

  No

• Do you have any experience using cannabis before:

  Yes

  No

• What conditions or symptoms do you have?

  Acute Pain

  Anxiety

  Arthritis

  Back Pain

  Bipolar Disorder

  Depression

  Endometriosis

  Chronic Pain

  ADHD

  Autoimmune Disorder

  Psoriasis

  Stress

  Acne

  Seizures

  Eczema

  PTSD

  Loss of Appetite

  Joint/Muscle Pain

  Insomnia

  Other

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*You confirm that the information given above is true to the best of your knowledge