Request edit access
Do I Qualify for Medical Marijua Treatment. Fill out Questionnaire and We will contact You
We would love to hear your thoughts or feedback on how we can improve your experience!
Do you Have Any of the Marijuana Qualifying Conditions for Florida *
Required
Preferred Time for Appointment on Wednesdays *
Required
Name *
Your answer
Phone Number *
Your answer
Email
Your answer
Preferred Method of Contacting you *
Required
I understand that to have a confirmed first appointment I will have to make full payment of 200 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. *
Required
Submit
Never submit passwords through Google Forms.
This form was created inside of Craft Behavioral Health, LLC. Report Abuse