Join The International Cannabis Patients Wall
A "Patient" for this purpose is any person, of any age, from any state that has a medical condition that is being or could be helped by the use of Cannabis therapies. The International Cannabis Patients Walls will be built to be displayed in the United states capitals and then all together in Washington to build a Display Wall over a mile long showing Patients from all over the world that stand united against cannabis prohibition. We raise our collective voices to bring attention to and spread awareness of the need for federal and world changes in legislation that are fair and equal for all people world wide.

Questions marked by an asterisk are mandatory to be represented on the National Cannabis Patients Wall Displays for any country, the state option is required for US Citizens. All other information is optional but will only be used to represent patients and their needs and by giving us the tools we need to validate patient needs as we fight for federal legalization.

Full First Name, Full Last Name or Initial *
Full first name and Last Name Full or Initial. is required.
Your answer
Current Status of Pediatric Patient / Adult Patient / Veteran Patient *
Choices with "illegal access" are available for those that choose full disclossure.
Is this a memorial post and or did this person pass while waiting for change in legislation?
Age *
Country of Residence *
If You Live in the United State Please Choose State of Residence
THIS IS REQUIRED TO BE LISTED ON YOUR STATE WALL
Are you a Medical Marijuana Refugee AKA an MMR?
Have you and or your family moved from your home state to obtain access to legal medical cannabis?
Medical Marijuana Refugee (MMR) Status?
If you are an MMR spedify the home state moved from and new state moved to.
Your answer
The illness/illnesses that do, would, or should qualify you as a cannabis patient *
Choose all that apply. If your illness is not on the list please choose "Other" and add below.
Required
Other Illnesses
If you chose Other above what illness do you feel should qualify you for medical cannabis.
Your answer
If you checked Cancer above please list the type of Cancer here.
Your answer
Do you have an illness that was caused by a pharmacutical prescribed to you for another illness?
If you have an illness caused by a pharmacutical prescribed to you for another illness list it here.
Diagosed illness, prescribed medication, and pharmacutical side effects of that prescription.
Your answer
.Are you currently a medically qualified patient in a legal state?
Following Questions Pertain to the Use of Medical Cannabis Therapies
If you are not able help with this section, you can submit your form now and thank you for your application. If you can help with this section we will use this information to help new patients with questions about using cannabis therapies.
What delivery method(s) do you use?
What sub species of cannabis works best for your symptems or healing therapy?
What cannabis product works best for your symptoms or healing therapy?
Is there a specific strain that works best for your symptoms or healing therapy?
Your answer
Are you prescribed a specific dosage per day?
If prescribed a dosage what are you instructed to use?
Your answer
Where or how do you obtain your medication?
Is it hard for you to obtain medication in your area?
Photos can be added if you choose. Go to our web site to find out how after you submit this.
Submit
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Additional Terms