Medicinal Cannabis Dispensary Request

Medicinal Cannabis Dispensary Request
Full Name*

First NameLast Name
Date of birth*

DayMonthYear
Address*

Street Address

Street

SuburbState / Province

Post Code
Email*
example@example.com
Phone Number*
Please Note: Due to recent policy changes, we are no longer able to offer in-person collection. All orders will be fufilled via delivery by authorised courier.

Express Post orders that are finalised before 11:30am are usually delivered by the next business day.

Please acknowledge by selecting the "Express Post" option below.
Preferred Delivery Method*

Express Post
Upload ID
Have you ever had a consultation at Inner North Medical Clinic?*

YesNo
Upload current driver's license*

Cancelof
Upload medicare card*

Cancelof
Upload Up To Three E-scripts
Product 1 name*
Product 1 E-script upload*

Cancelof
Product 2 Name
Product 2 E-Script Upload

Cancelof
Product 3 Name
Product 3 E-Script Upload

Cancelof
I have read the side-effects and terms and conditions on this page*

Yes
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