Cannabis Commonwealth Patient Survey
Do you believe cannabis will help your medical condition? Have you traveled to another state for treatment? Are you ready to share your story? Complete the Cannabis Commonwealth Patient Survey and join the coalition of patients, parents, professionals and policy makers working to expand medical cannabis access in Virginia. Information may be shared anonymously, or you can register to actively participate in lobbying legislators. Stories will be complied in a presentation to Virginia state lawmakers.

Cannabis Commonwealth is a nonprofit corporation registered in Virginia and is not a Health Plan or Health Service Provider, and is not covered under HIPAA.

First Name
Your answer
Last Name
Your answer
Address
Your answer
City *
Your answer
State *
Your answer
Zip *
Your answer
Email *
Your answer
Phone
Your answer
Are you a patient or a caregiver? *
Please describe the patient’s medical condition for which you believe cannabis may be efficacious. *
Your answer
Which pharmaceuticals or traditional therapies is the patient currently using or has the patient tried for this condition? *
Your answer
Please describe any side effects the patient has experienced from pharmaceutical or traditional therapies. *
Your answer
Which FDA-regulated medications do you believe the patient would be able to decrease with medical cannabis? *
Your answer
How else do you believe medical cannabis would improve the patient’s condition? *
Has the patient ever moved to have access to state-legal, regulated medical cannabis? *
Have you contacted your elected state representatives regarding medical cannabis? *
Are you interested in meeting with your elected state representatives to discuss medical cannabis access? *
Are you interested in lobbying for medical cannabis access during the Virginia General Assembly session? *
Please include any additional comments here that you would like to share with members of the Virginia General Assembly regarding the patient’s need for medical cannabis access.
Your answer
Please select how you would prefer your patient story be presented to legislators. *
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