Patient Qualification - MCC Marijuana Doctor

Name *

First

Last

Phone *

Email *

Please select your medical condition *

My condition affects my everyday life *

I have constant pain from my condition *

I can not do the things I enjoy because of my condition *

I have been prescribed medications with the the possibility of addiction and or adverse side effects *

I do not sleep well or at all because of my condition *

My condition has impacted my relationship with friends and or loved ones *

I have had to alter my life drastically because of my condition *

If medical marijuana is able to help with my condition, It would make my quality of life much better *