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Contact Details

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First Name*

Last Name*

Email Address*

Contact Number*

Date of Birth*

Gender*

Password*

Please make sure your password is a minimum 12 characters.

Confirm Password*

The passwords you have entered don't match.

Shipping Address

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Address Line 1*

Address Line 2

City*

State*

Postal Code*

Country*

Are you a Business? Yes

Type of Business

Business Name

Business Address Line 1

Business Address Line 2

Business City

Business State

Business Postal Code

Business Country

Medical Conditions

Please tick all that apply

Please ensure all required fields are filled in correctly.

ADHD Yes

Agoraphobia Yes

Anxiety Yes

Appetite Disorders Yes

Arthritis Yes

Autistic Spectrum Disorder Yes

Back and Neck Pain Yes

Bipolar Yes

Bladder Pain Yes

Cancer Pain and Nausea Yes

Chrohn's Disease or Colitis Pain Yes

Chronic and Long Term Pain Yes

Chronic Fatigue Syndrome (CFS) Yes

Cluster Headaches Yes

Complex Regional Pain Syndrome Yes

Depression Yes

Dermatology Yes

DVT Yes

Ehlers-Danlos Syndrome (EDS) Yes

Epilepsy Yes

Endometriosis Yes

Female Gynaecological Pain Yes

Fibromyaalgia Yes

Irritable Bowel Syndrome (IBS) Yes

Migraine Yes

Multiple Sclerosis Pain and Muscle Spasm Yes

Nerve Pain Yes

OCD Yes

Osteoporosis Yes

Pakinson's Disease Yes

Personality Disorder Yes

Phantom Limb Pain Yes

Post Traumatic Stress Disorder (PTSD) Yes

Sciatica Yes

Scoliosis Yes

Sleep Disorders Yes

Spondylolisthesis Yes

The Menopause Yes

Thalasemia Major Blood Disorder Yes

Tinnitus Yes

Tourette Syndrome Yes

Trigeminal Neuralgia Yes

Other Medical Conditions

Prescribed Medicines & Treatments

Please tick all that apply

Please ensure all required fields are filled in correctly.

Alprazolam Yes

Alfentanil Yes

Amitriptyline Yes

Atomoxetine Yes

Azathioprine Yes

Buprenorphine Yes

Bupropion Yes

Citalopram Yes

Clonazepam Yes

Codeine Yes

Codeine Phosphate Yes

Co-Codamol (30/500) Yes

Dexamfetamine Yes

Diazepam Yes

Diclofenac Yes

Dihydrocodeine Yes

Fentanyl Yes

Fluoxetine Yes

Fluoxetine (Prozac) Yes

Gabapentin Yes

Guanfacine Yes

Infliximab Yes

Lisdexamfetamine Yes

Lithium Yes

Lorazepam Yes

Melatonin Yes

Menthylphenidate Yes

Meptazinol Yes

Methadone Yes

Methotrexate Yes

Mirtazapine Yes

Modafinil Yes

Morphine Yes

Naproxen Yes

Nefopam Yes

Nortripyline Yes

Omepresol Yes

Omezrapol Yes

Oxycodone Yes

Paroxetine Yes

Pentacozine Yes

Pethidine Yes

Prednisolone Yes

Propranolol Yes

Remifentanil Yes

Sertraline Yes

Sodium Valproate Yes

Suvorexant Yes

Tapentadol Yes

Temazepam Yes

Tramadol Yes

Trazodone Yes

Triazolam Yes

Venlafaxine Yes

Zolpidem Yes

Zopiclone Yes

Other Prescribed Medicines / Treatments

Medical History (Part One)

Please ensure all required fields are filled in correctly.

Do you have a history of heart problems?*

Including palpitations, heart attack (MI), stroke, angina, chest pain, shortness of breath, arrhythmias (funny heart beats), pacemaker, or taking any heart medications

True
False

Are you currently being treated for cancer or undergoing any cancer treatments?* Yes
No

Are you currently taking Immunosuppressants or Immunotherapy medication?* True
False

Do you have any history of Liver Disease including hepatitis, elevated liver enzyme function blood tests, fatty liver cirrhosis?* True
False

Psychiatric history - Have you ever been referred to a psychiatrist health service?* Yes
No

Have You Ever Been Diagnosed With?* Schizophrenia Depression Anxiety Disorders including Generalized Anxiety disorder, OCD or other? Mania (bipolar disorder) Personality Disorder PTSD None

Are you currently or previously suicidal?* Yes
No

Does anyone in your direct family suffer from any of the following conditions?*

(i.e. parent/sibling/cousin/uncle/aunt/child)

Psychosis Schizophrenia Schizoaffective Disorder Anxiety Depression Bipolar/Manic Depression/Mania None

Medical History (Part Two)

Please ensure all required fields are filled in correctly.

Do you have a history of alcohol abuse or dependency?* Yes
No

Have you ever been under the care of drug and alcohol services?* Yes
No

How many units of Alcohol do you drink per week?*

Do you use cannabis to reduce or eliminate the use of any medications that have been prescribed for your medical condition?* Yes
No

Cannabis History - If you do use cannabis currently, how often do you use cannabis?* Everyday
Every other day
1-2 times per week
Never

How have you used cannabis?* Smoking (Joints) Vaporizing Ingestion Topical Never

How much cannabis do you currently use per day? (in Grams)*

Have you had any serious reaction to cannabis?* Yes
No

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Contact Details

Shipping Address

Medical Conditions

Please tick all that apply

Prescribed Medicines & Treatments

Please tick all that apply

Medical History (Part One)

Medical History (Part Two)

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