Request edit access
Do I Qualify for Medical Marijua Treatment. Fill out Questionnaire and We will contact You. NO INSURANCE COVER THIS SERVICE.
Do you Have Any of the Marijuana Qualifying Conditions for Florida
Human immunodeficiency virus (HIV)
Acquired immune deficiency syndrome (AIDS)
Post-traumatic stress disorder (PTSD)
Amyotrophic lateral sclerosis (ALS)
A terminal condition
Other Medical conditions of the same kind As Above
Any Other Conditon
Do you have Medical records supporting diagnosis of any qualifying conditions
Yes (I will bring record with me for my first appointment)
Preferred Method of Contacting you
I understand that to have a confirmed first appointment I will have to make full payment of 100 Dollars. If I am not qualified then the 50% of the deposit will refunded. I further agree that if I qualify to be appropriate for such treatment then I am willing to participate in the membership program of Medical Marijuana treatment program of Craft Clinic (a subsidiary of Craft Behavioral Health). I agree to provide a credit card for auto deduction of 29 dollars a month. This subscription can be cancelled any time however cancellation of subscription or declined payments of credit card will be considered termination of participation in program. I also agree to go through random drug screen. If I am a female of child bearing age I understand I am required to notify if I get pregnant during the course of treatment, as soon as possible. PLEASE NOTE YOU MAY RECEVIE A CALL FROM A PRIVATE NUMBER.
Never submit passwords through Google Forms.
This form was created inside of Craft Behavioral Health, LLC.