Intake form

Help us serve you better

Name *

Email address *

Phone number

What is your primary reason for seeking a medical marijuana prescription?

Please select at least one option.

Chronic pain

Anxiety

Depression

Insomnia

PTSD

Cancer

Other (please specify)

Do you currently have a physician?

If yes, please provide the physician's name and contact information.

Have you previously received a medical marijuana prescription?

Are you currently taking any medications?

What is your preferred method of communication?

How did you hear about tree-iage solutions inc.?

What is your preferred appointment date and time?

Additional questions or comments

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Tree-iage Solutions Inc.