ALL FORMS MUST BE COMPLETED BEFORE YOUR 1ST ORDER. IF FORMS ARE NOT COMPLETED YOUR ODER WILL NOT BE PROCESSED, UNTIL FORMS ARE COMPLETED.

Patient Information Form

Medical condition(s) and symptom(s): (Please click any of the conditions below that apply to you)











Have you used cannabis before without adverse effects?



Have you made efforts to access your cannabis medicine through the government's mail order program?



I hereby declare that that the information stated above is factual:

Electronic Signature Agreement. By selecting the "I Accept" button, you are signing this Agreement electronically. You agree your electronic signature is the legal equivalent of your manual signature on this Agreement. By selecting "I Accept" you consent to be legally bound by this Agreement's terms and conditions.

THESE FORMS ARE TO PROTECT RED EYE DELIVERY. ALL INFORMATION COLLECTED WILL NOT BE SHARED IN ANY WAY! INFORMATION WILL BE STORED OFF SITE IN A SECURE LOCATION. INFORMATION WILL NOT BE STORED IN A DIGITAL FORMAT OR ON A CLOUD, ALL INFORMATION WILL BE STORED IN A HARD COPY FORMAT OFF SITE.

WE APPRECIATE YOUR CO-OPERATION AND TRUST. 

© Red Eye Delivery 2018