Information Request Form

right:ratio

Information Request Form (Human)
Patient

First Name Last Name
E-mail
Date

Month Day Year
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
Phone Number

Area Code Phone Number
Age
Weight
Male Female
General information required:

1) Have you suffered from any of the following conditions?
Arthritis Anxiety Pain Cancer Other
Urinary Disease Respiratory Disease Heart Disease Seizure Disorder
Gastrointestinal Disease Skin Disease/Allergies Ocular Disease Liver disease
If other, specify:
What conditions are you seeking to support with right:ratio?
What medications are you currently taking?
Do you have allergies to any drugs, foods, vitamins? If yes, please list below.
What benefits are you looking for right:ratio to provide?
Have you in the past or are you currently using cannabis in any form? If so, in what form and how often?
Have you tried other cannabis products for medical conditions? If so, please list the condition, the product and the result.
How did you hear about right:ratio?
Additional Comments:
Should be Empty:

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