Emergency Medical Prescription – Smith Collective

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Contact
Treatments
About Us
Upload Script
Medication Form
Emergency Prescription
Nicotine
Login

Contact
Treatments
About Us
Upload Script
Medication Form
Emergency Prescription
Nicotine
Login

Contact
Treatments
About Us
Upload Script
Medication Form
Emergency Prescription
Nicotine
Login

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Emergency Medical Cannabis Prescription

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- Step 1 of 4

I acknowledge that: *

I am the patient requesting the medical consult

Age *

I am over 18 years of Age

Medical Fee *

Medical private fee of $50 will be charged per consult

effects select treatments

Please select the reason(s) for emergency consult request *

I am unable to contact my usual Doctor
My current medication isn't helping and I need a second opinion from another Doctor

Name *

First

Last

Mobile Phone *

Home Phone

Email *

Date of Birth *

Address *

Address Line 1

City

State / Province / Region

Postal Code

Country

Upload Medicare Card

Click or drag a file to this area to upload.

Upload Concession/DVA/Pension Cards

Click or drag a file to this area to upload.

Upload Drivers License/Passport/Photo ID

Click or drag a file to this area to upload.

What are your medical conditions? *

Acute Pain
Anxiety
Arthritis
Autism
Auto Immune
Cancer
Chemo induced nausea and vomiting
Chronic Pain
Degenerative Disease
Depression
Dystonia
Epilepsy
Fibromyalgia
Insomnia
Loss of Appetite
Mental Health
Migraines
Movement Disorders
Multiple Sclerosis
Muscle Pain
Muscle Spasms
Nerve Pain
Neurological
Osteoarthritis
Pain Inflammation
Panic Attacks
Psoriasis
PTSD
Seizure Management

Have you ever self-medicated or are you currently self-medicating with cannabis? *

Yes
No

What other treatments have you tried for this condition? *

What medications have you previously used? List any side effects and your reason for stopping. *

Current Medications (Include Medicinal Cannabis and other prescription Medications) *

Do you have any allergies, if yes please list: *

Yes
No

allergies *

Do you currently experience, or have a history of, the following? *

Drug dependence or substance abuse or on the Opioid Treatment
Psychosis (Taking antipsychotic medications)
Bipolar Disorder
Cardio-respiratory
Mood disorder or severe
Anything else you would like to mention:
None of the above

Anything else you would like to mention: *

Are you pregnant, breastfeeding, or considering *

Yes
No

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