Free Medical Consultation Form
Please fill the form to get Medical Advice from our doctors.
Note: Free Consultation Only Applicable for Neet CBD Products
Patient Name
*
First Name
Last Name
Phone Number
*
-
Area Code
Phone Number
Email
example@example.com
Age
*
Gender
*
Female
Male
Other
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Health Check
Fill the Details
Heart Rate
Blood Pressure (in mmHg)
Height (in feet and inches) *
Weight (in kilograms) *
Blood sugar (in gm/dl)
Please explain why do you want a consultation?
*
History of past illness (if any)
*
Family History (Does any of your blood relation suffer from similar illness):
*
Drug History ( Do you use any drug, alcohol or tobacco habitually )
*
Do you have any experience of using cannabis in any form ? if yes please explain in which form and side effects if any
*
Rate your sleep on scale 1 to 5:1
*
Worst
1
2
3
4
Best
5
1 is Worst, 5 is Best
Are you allergic to any drug, antibiotic or any other supplement?
*
Current Medication, If any
*
Please upload medical documents (if any)
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Cancel
of
Consultation Appointment
Please verify that you are human
*
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