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
Your answer
Email Address
Your answer
Phone Number
Your answer
Have you spoken to your provider (physician or APN) about the Therapeutic Cannabis Program?
Yes
No
Clear selection
Is your provider willing to certify you for the program at this time?
Yes
No
Clear selection
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:
Clear selection
Did your provider have questions regarding the program's paperwork and/or process?
Yes
No
Not Applicable
Clear selection
Would you be interested in learning more about providers in the area who would be willing to certify you for the therapeutic cannabis program?
Yes
No
Clear selection
Please provide any additional questions or comments below. We'd love to hear from you!
Your answer
Submit
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