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CONSULTANT APPLICATION
Individual Educational Consultation
PERSONAL INFORMATION
Guardian's Names *
Name of Child *
Child's Birthdate *
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DD
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Phone number *
Email *
Address
Our family or my child currently receives:
YOUR CHILD'S INFORMATION
Please explain your child's diagnosis: *
Hospitals where your child is treated & lead physician: *
QUESTIONS
Describe your child's diagnosis and disability. Please include the date that your child was diagnosed. *
Briefly explain what treatments have been tried in the past and why you are interested in learning more about alternative plant medicine. *
Have you discussed using alternative plant medicines such as cannabinoids with your child's medical team? *
Required
How often does your child's diagnosis affect their quality of life such as attending school, playing, eating, and sleeping.  *
Required
Purpose for Request
Terms of Service & Privacy: Rylie's Smile Foundation collects data in order to further research of cannabinoid therapy for severe pediatric diagnosis. Rylie's Smile keeps all personal identifying information confidential. However, I understand that medical records or information that I share as my child's guardian could contain sensitive medical information. I understand that if the person or entity that receives the information is not a health  care provider covered by federal privacy regulations, the information described may be re-disclosed and no longer protected by these regulations. I hereby affirm that I have read and fully understand the above statements and consent to the disclosure of the medial information as it pertains to my child'd diagnosis.
By clicking "yes" you agree to abide by the Terms of Service and Privacy outlined above. *
Electronic Signature *
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