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Application – Heart of The Dispensary

Application for Heart of The Dispensary

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Date:

Name:

Member number:

Preferred contact (phone # or email) :

Do you wish to be anonymously featured in this project?    No     YES (put anonymous below)

What name would you like used ? Please spell it out here exactly as you wish it to appear:
___________________________________________________

Optional

Please describe a way cannabis has made a difference in your health.

Please describe a way in which having access to cannabis has helped your family or loved ones.

Do you recommend the services of The Medicinal Cannabis Dispensary to others and why?

What is your favourite strain? __________________________________________________
Favourite type of medicinal cannabis used? _______________________________________
Favourite method of ingestion? _________________________________________________
An organization close to your heart?________________________________
Do they have a website? _______________________________________________________

For Office Use Only

Name on project: ___________________________________

File name: ________________________________________

Waiver signed /dated?       No     Yes       Reviewed by __________________