Licence to Grow Form

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Name*
First Last
Email*
Phone*
What is your occupation?*
What is your birth date?*

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MM
YYYY

Please note you must be 20 years or older to obtain a licence.
What is your Skype ID or email you used to create your Skype account?*
If you don't have an account please visit www.skype.com to register (phone or computer). For existing Skype users please add Skype username: Cannabis_Consulting
Click Here for help finding your Skype ID
Current Address*
Street Address Address Line 2 City Province Postal Code
Is the address above the same as your mailing address?*
What is your mailing address?*
Street Address Address Line 2 City Province Postal Code
How did you hear about us?*
What is the name of the store?*

Chief problem(s) for which medical cannabis is being requested:
List all your current medications including dosage
List any medications you are allergic to:
Do you use cocaine or other “street” drugs?*
Please list any street drugs do you currently use and how often you use them.
Do any of your medications contain opiates? (Codeine, Morphine, etc.)*
Do you currently use cannabis for relief?*
Please check all that apply.
- vapor
- edible
- topical
- smoke
How much cannabis are you hoping to obtain? (grams per day ) :*
How often do you use cannabis?*
How often do you intake cannabis?
Have you ever experienced an unpleasant /unwanted side effect of marijuana? (*
Please describe your side effect.
Are you aware of the possible side effects that may occur from use of marijuana?*

Do you currently hold a prescription for medical cannabis?*
How many grams do you currently have a persciption for?
Do you have or have you ever had any of the following medical conditions:
- Asthma/Lung Disease
- Hepatitis
- Stroke
- Kidney Disease
- Thyroid
- Heart Disease
- Cancer
- ADD/ ADHD
- Substance Abuse
- Depression
- MS
- Schizophrenia
- Hyper Tension
- No, I have not had any of these
Please check all that apply
List the name, last date seen and type of health care provider (doctor, chiropractor, therapist, psychologist, counselor, specialist or other (please specify) that you consult for your medical condition(s):
Have you had any prior surgeries?
Do you currently use tobacco products?*
How often do you use tobacco per week?
Do you consume alcohol?*
How oftern do you drink alcohol per week?*
Please add any notes you feel are of importance

Throughout our lives, most of us have had pain from time to time (such as minor headaches, sprains and toothaches). Have you had pain other than these everyday kinds of pain today?
Which area do you feel pain the most?*
Please rate your pain by checking the one number that best describes your pain at its worst in the past 24 hours.*
Please rate your pain by checking the one number that best describes your pain on average.*
Please rate your pain by checking the one number that best describes how much pain you have right now.*
In the past 24 hours, how much relief have pain treatments or medications provided? Please check the one percentage that most shows how much relief you have received*
In the past 24 hours how much has pain interfered with your general activity?*
In the past 24 hours how much has pain interfered with your mood?*
In the past 24 hours how much has pain interfered with your walking ability?*
In the past 24 hours how much has pain interfered with your work?*
In the past 24 hours how much has pain interfered with your relationships with other people?*
In the past 24 hours how much has pain interfered with your sleep?*
In the past 24 hours how much has pain interfered with your enjoyment of life?*
In the past 24 hours how much has pain interfered with your ability to concentrate?*
In the past 24 hours how much has pain interfered with your appetite?*
In the area where you have pain, do you have “pins and needles”, tingling or prickling sensations?
- Yes
- No
Does the painful area change colour (perhaps mottled or red) when the pain is particularly bad?
- Yes
- No
Does your pain make the affected skin abnormally sensitive to the touch?
- Yes
- No
Does your pain come on suddenly and in bursts for no apparent reason when you are completely still?
- Yes
- No
In the area where you have pain, does your skin feel unusually hot like burning pain?
- Yes
- No
Gently rub the painful area with your index finger and then rub a non-painful area. How does the rubbing feel in the painful area?
- No difference
- Discomfort – pins and needles, tingling or burning in the painful area
Gently press on the painful area with your fingertip then gently press in the same way to a non painful area. How does this feel in the painful area?
- No difference
- Discomfort – pins and needles, tingling or burning in the painful area

HADS (Hospital Anxiety & Depression Scale) - Please read each statement below and choose the number which best describes how true the feeling is for you.
I wake early and then sleep badly for the rest of the night.
I get very frightened or have panicked feelings for apparently no reason at all.
I feel miserable and sad.
I feel anxious when I go out of the house on my own.
I have lost interest in things.
I get palpitations, or sensations of “butterflies” in my stomach or chest.
I have a good appetite.
I feel scared or frightened.
I feel life is not worth living.
I still enjoy the things I used to.
I am restless and can't keep still.
I am more irritable than usual.
I feel as if I have slowed down.
Worrying thoughts constantly go through my mind.
Upload a clear photo of your ID (drivers licence, health card, or passport)*
Drop files here or

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Please review our terms and conditions*
- I agree to the Terms and Conditions

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