Clover CBD Patient Consulting Form
This quick survey will help us personalize your first consulting session with us!
Email address *
What is your date of birth? *
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YYYY
What is your name?
Your answer
How familiar with CBD (Cannabidiol) are you?
Very little
Very familiar
Please check all the symtoms/conditions you are experiencing
What medications are you currently taking?
Your answer
Are you using any forms of holistic medicine?
Your answer
How active would you describe your lifestyle?
Inactive
Extremely Active
Do you currently smoke or vape?
What method of ingestion do you prefer?
What do you hope to achieve by using CBD?
Your answer
Is there anything else you would like us to know before coming to visit us?
Your answer
Please let us know what day you would like to visit.
MM
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DD
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YYYY
Is there a time that works best for you?
Time
:
A copy of your responses will be emailed to the address you provided.
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