GVW Application Form

Personal Information
Name as it appear on Health Card *

First Name Last Name
Date of Birth *

Day Month Year
Date
Phone Number *
Please enter a valid phone number.
Email *
example@example.com
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
How to did you find out about our clinic? *
Are you Veteran? *

Yes No
K#
Will you be applying to Health Canada for your ACMPR license ("grow license")? *

Yes No
Are you a First Responder? *

Yes No

Patient Consent to Disclose Information
I, First Name* Last Name* , hereby acknowledge that all the information provided by me is truthful and does not contain any information that might mislead the process.
Please attach your Photo ID and Medical documents:

Cancel of
Acknowledgement *

Clear
Should be Empty:

	Not at all	Several Days	Over half the days	Nearly everyday
1. Feeling nervous, anxious, or on edge
2. Not being able to stop or control worrying
3. Worrying too much about different things
4. Trouble relaxing
5. Being so restless that it's hard to sit still
6. Becoming easily annoyed or irritable
7. Feeling afraid as if something awful might happen

	Not at all	Several Days	Over half the days	Nearly everyday
1) Little interest or pleasure in doing things.
2) Feeling down, depressed, or hopeless
3) Trouble falling or staying asleep, or sleeping too much
4) Feeling tired or having little energy
5) Poor appetite or overeating
6) Feeling bad about yourself—or that you are a failure or have let yourself or your family down
7) Trouble concentrating on things, such as reading the newspaper or watching television
8) Moving or speaking so slowly that other people could have noticed? Or the opposite — being so fidgety or restless that you have been moving around a lot more than usual
9) Thoughts that you would be better off dead or of hurting yourself in some way

Personal Information