MMJPR - Client Request Form v3

Who do you want to speak with? *

Medical Cannabis Doctors & Clinics Licensed Cannabis Producers

Full Name *

First Name Last Name

Phone Number

Area Code Phone Number

Province *

Email *

Client Checklist - Doctors & Clinics (check all that apply):

I want to video chat with a doctor online I want to meet my doctor in-person I want a prescription for medical marijuana. I am over the age of 25 (Not Required!) I am a Veteran I have been diagnosed by a physician. I have a medical report less than 7 years old I want to grow my own medical cannabis

Client Checklist - Licensed Marijuana Producers (check all that apply):

I have my doctor signed medical document My prescription has expired. I need to renew. I don't have a signed prescription from a doctor I am currently registered with a LP I am a Veteran I prefer to order online I prefer to order by phone I want to grow my own medical cannabis

Medical Condition

Message

Preffered Contact Time *

Morning Afternoon Evening

Terms *

I accept the MMJPR.ca Terms & Conditions.

Send my client request to several companies within the category I've specified above in this form. By submitting this form, I give consent for companies listed in this category to contact me with information about my client request and agree to our terms & conditions.

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Note: Client requests are a resource for use by prospective clients to request information directly from Producers/Doctors/Clinics/Vendors/Suppliers. Solicitation for business or misuse of this client request tool is strictly prohibited.