Name (*)

Email

Phone #1 (*)

What times are you available at this number?
 Morning Afternoon Evening

Phone #2

What times are you available at this number?
 Morning Afternoon Evening

Age:

Minors are only permitted to apply with written parental consent and a statement from a doctor who will sign their MMAR application forms.

Gender:  male female

How did you find us?

 Google/Internet Search Your Doctor Another VIMM Patient Friend or Family Member Magazine or Newspaper Canadian AIDS Society Canadian Cancer Society Other

Newsletter:

 Yes, sign me up for occasional VIMM news updates by email

Are you applying as a patient or a grower?
 Patient Grower

Please explain briefly your reason(s) for applying, and let us know how we can best help you.

If you are applying as a patient, please complete sections 3 & 4 as well. Otherwise, proceed to section 5

Do you have an MMAR number?  Yes No

If you answered "Yes", please enter your MMAR Information. If you answered "No", skip the MMAR Information section and proceed to the Health Canada Application section.

MMAR Information

Health Canada MMAR Number

Expiration Date: ---JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember ---12345678910111213141516171819202122232425262728293031 ---2002200320042005200620072008200920102011201220132014201520162017201820192020

Health Canada Application

Do you have all your Health Canada forms ready to submit?
 Yes No

Has your doctor agreed to sign your Health Canada forms?
 Yes No

Your Condition(s)

Check any of the following conditions that you have been diagnosed with and/or are currently suffering from:

Category 1

 Multiple Sclerosis Cancer HIV/AIDS Severe Arthritis Spinal Cord Injury Spinal Cord Disease Epilepsy

Category 2

 ADD/ADHD Arthritis Accident or Trauma Brain Injury Head Injury Chronic Nausea Crohn's Disease Fibromyalgia Irritable Bowel Syndrome Muscular Dystrophy Sleep Disorders Hepatitis C Anxiety Bi Polar Disorder Eating Disorders Asthma Alzheimer's Disease Chronic Pain Colitis Kidney Failure/Dialysis Glaucoma Hypertension Migraines Muscle Spasms Parkinson's Disease Depression Post Traumantic Stress Disorder Gastrointestinal Disorders Other

Please describe as much as you can about your condition, diagnoses, history and the treatments you have already tried. Include any medications you have already used and how they have helped or not helped.

Amount of expected daily usage:

Strains

Are there particular strains that you find are more effective in treating your symptoms?
 Sativa Indica Not Sure

Methods

What are your preferred methods of consuming medical marijuana?
 Vaporizing Foods Infusion (Tea) Tinctures Smoking

 I have read, understood and agreed to the privacy policy (view)

 I am a Canadian citizen or permanent resident and currently reside inside Canada

 I am over the age of 18 or have written parental permission to apply for VIMM's services