Patient Registration Form

Update Patient Information:

Existing Members - Membership Number

* Title

* Full Name

*Surname

* Identification Type

*Id Number

Date Of Birth

Age

Weight (kg)

Height (cm)

*Gender

Occupation

* Phone

* Email Address

*Upload Front Id / Passport

Upload Back Id

*Upload Selfie Image

*Select Preferred Dispensary

Address Information:

*Address Line 1

*Address Line 2

*City

*Postal Code

Country

Emergency Contact Information:

*Name

*Relationship

*Phone Number

Password Information:

* Password Password must be at least 6 characters long, contain an uppercase letter, lowercase letter and a numeric value

* Repeat Password

Medical Cannabis Use:

* Have you previously used cannabis for medical purposes?

If yes, please describe your experience.

* What condition are you aiming to treat with medical cannabis?

*Have you experienced any adverse reactions from cannabis use in the past?

If yes, please describe:

Cannabis Use History:

* Have you used cannabis before?

If yes, please describe your experience:

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Medical Information:

* Primary Healthcare Provider

* Healthcare Provider Contact Number

* Existing diagnosis from DR. Please supply Dr details

Have an existing prescription for cannabis gladly provided us with a copy

Medical History:

* Current Medications

* Allergies (if any)

* Previous Medical / Surgical History and any significant injuries

History of:

ADD/ ADHD

Anxiety

Depression

Insomnia

Panic Attack

PTSD

Psychosis

Substance Abuse Disorder

Cigarette smoking

Alcohol use

Current ongoing medication

Family History:

Diabetes

Hypertension

Asthma

Cholesterol

Cancer

Previous use of illegal substances

Relating to current treatment:

Orthodox Medication

Stop such medication?

History of cannabis use

Age when started

Current use per day or week?

Joints

Vapes

Gummies

Edibles

Oils

Preferred strains

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Patient Declaration & Signature

Declaration

1. I am over the age of 18 years old.
2. I am not addicted to habit-forming substances, including controlled substances.
3. I am not engaged in the illegal buying, selling, or dealing of any restricted or controlled substances.
4. I understand that any information or materials provided to me are intended for legal and informational purposes only.
5. I acknowledge that any use of substances, materials, or information obtained through this channel is at my own risk, based upon the prescription from my traditional healer and I will adhere to script and all applicable laws and regulations.
6. I shall not resell any of the items received in terms of the script for medical cannabis, as it is intended for my personal medical used only.
7. I understand that this confirmation is a material representation upon which reliance is placed, and any false statements may lead to legal consequences.

I hereby declare that the information provided in this questionnaire is accurate and complete to the best of my knowledge. I understand the importance of disclosing my medical history for the purpose of receiving appropriate medical cannabis recommendations.

SIGNED at on 2025

Name ID Number

* Signature

Signature Accepted