MMJPR - Client Request Form v3

Who do you want to speak with?*

Medical Cannabis Doctors & ClinicsLicensed Cannabis Producers

Full Name*

First NameLast Name

Phone Number

Area CodePhone Number

Province*

Email*

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

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

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

I have my doctor signed medical documentMy prescription has expired. I need to renew.I don't have a signed prescription from a doctorI am currently registered with a LPI am a VeteranI prefer to order onlineI prefer to order by phoneI want to grow my own medical cannabis

Medical Condition

Message

Preffered Contact Time*

MorningAfternoonEvening

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.