Licence to Grow Forms

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

DD
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 often do you use cannabis?*
How often do you intake cannabis?
Have you ever experienced an unpleasant/unwanted side effects of cannabis?*
Please describe your side effect.*
Are you aware of the possible side effects that may occur from use of cannabis?*
Have you ever been diagnosed with schizophrenia?*
Have you ever been diagnosed as bipolar?*
Are you on any psychiatric medications?*
Please list your medications and daily dosage.*
Have you ever been diagnosed with any form of autism?*
How would you rate your cannabis growing skills?*

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.
Have you ever thought about committing suicide?
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.
Please add any notes you feel are of importance
Upload a clear photo of your ID (drivers licence, health card, or passport)*
Drop files here or

Accepted file types: jpg, jpeg, gif, png, pdf.
Please review our terms and conditions*
- I agree to the Terms and Conditions
Can you confirm all your answers are truthful without omission?*
- Yes, I confirm

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