CBD/THC Follow-Up Visit

First Name

Last Name

Phone

Please List Qualifying Medical Conditions:

Are you experiencing any adverse side effects?

What is your current weight?

Has anything changed since your last appointment?

Have you noticed improvement in quality of life?

Do you feel max management has been reached?

Were you compliant with RX directions?

Check what applies

Were you satisfied with previous RX dosage?

Check what applies

What is your current daily dosage?

Are you taking the maximum daily dosage?

Check what applies

Billing Address

Address Line 1

Address Line 2

City

Country

Select

State/Province

Select

Zip Code

Sub Total

$99.00

TOTAL

$99.00

Payment Method

Credit Card - Square

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Thank you for follow up Telemedicine Order

Thank you for your Telemedicine appointment order. We will send you an email with exact instructions on how to set up your patient portal. Then, you will be contacted at the exact time of your Telemedicine appointment.

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