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Location *

Title *

First Name *

Last Name *

Age *

Weight (kg) *

Height (cm) *

Occupation *

Phone Number *

Street Address *

Street Address Line 2

City *

Province *

Postal / Zip Code *

Upload ID / Passport

Reason for application to use unregistered medication *

Insomnia

Chronic Pain (> 3 months)

Anxiety

Back / Neck Pain

Epilepsy

Neuropathic Pain

Multiple Sclerosis

Endometriosis

Chemotherapy Induced Nausea and Vomiting

Arthritis

Fibromyalgia

Palliative Care

Other

Eligibility Declaration *

I confirm that I am over the age of 18.

I have never been diagnosed with Schizophrenia or Psychosis.

I confirm that I am not pregnant or breastfeeding.