Patient Registration Survey

Thank you for taking the time to fill out our first survey, your feedback is extremely helpful in ensuring a successful therapeutic cannabis program. Please forward to other potential patients to provide additional feedback.

Name

This is a required question

Email Address

This is a required question

Phone Number

This is a required question

Have you spoken to your provider (physician or APN) about the Therapeutic Cannabis Program?

This is a required question

Is your provider willing to certify you for the program at this time?

This is a required question

If your provider did not certify you, what was the reason given?

Did not know a program existed
Did not believe cannabis was a medicine
Did not feel comfortable undergoing the process
Lacks education and information to make an informed decision
Not Applicable, I've been successfully certified
Other:

This is a required question

Did your provider have questions regarding the program's paperwork and/or process?

Yes
No
Not Applicable

This is a required question

Would you be interested in learning more about providers in the area who would be willing to certify you for the therapeutic cannabis program?

This is a required question

Please provide any additional questions or comments below. We'd love to hear from you!

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