HRC Beta Client Intake Form

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DISCLAIMER

Thank you for your interest in The Herbal Rubik’s Cube (HRC) Beta Study. Your participation is voluntary, and your data will be used solely for research purposes, ensuring confidentiality and compliance with applicable laws. Please note that participation does not substitute medical advice; consult your healthcare provider before making any decisions. HRC does not guarantee the accuracy of the provided information. By submitting this form, you consent to participate and agree to these terms, as well as to our Privacy Policy and Terms of Service available on our website.

SECTION 1: USER / PATIENT INFORMATION

Who is filling out this form?
Full Name
Address
Date of Birth
ARE YOU A MILITARY VETERAN?

SECTION 2: MEDICAL CANNABIS PATIENT INFO (if applicable)

If no, skip to Section 3
A Registered Caregiver is someone you may appoint to act on your behalf in obtaining medication at the dispensary. If you believe that a caregiver will be necessary, please contact your authorizing physician for registration instructions.

SECTION 3: CANNABIS GOALS

Have you ever tried cannabis?
If Yes, Frequency of Cannabis (Marijuana) Use:
Are you primarily using cannabis for medical or recreational reasons?
Briefly explain your goal or intended outcome for using cannabis and/or why did you decide to use cannabis?
Please describe any positive effects experienced when using Cannabis (check all that apply)
Please describe any negative effects experienced when using Cannabis (if applicable):
List any qualifying medical condition(s) (if applicable):
List each medication, dosage and frequency on a new line.
List each OTC medication, dosage and frequency on a new line.
List each product, dosage and frequency on a new line.
Do you consume alcohol?
Do you use tobacco or nicotine products?
Do you use any other drugs?
Regarding your immune system, are you looking to:
Would you like to join our newsletter?
Do you hold a position in the cannabis industry?

**Please note: By participating in the HRC Beta Study, I acknowledge that the study is for personal use only and cannot be used for business purposes or shared in any way.

NOTICE OF PRIVACY PRACTICES ACKNOWLEDGEMENT, TERMS OF SERVICE & PRIVACY POLICY

Type your full name here to agree that you acknowledge the statement above.