Roxi Gray | New Client Intake form

 

Please Fill out as much as possible so Please take a moment for all first time Roxi Gray patients, and fill out this form so we can learn a little more about you and how we can help.we know how to best assist you:

Your Name (required)

Your Email (required)

Medical Card - (this is REQUIRED before we can proceed in creating your file)

Driver License or State ID - (this is REQUIRED before we can proceed in creating your file)

How did you hear about us?

What has your experience been so far with cannabis?

What is your Tolerence? Low 1: (10mg) - High 10: ( 100mg)

What are you trying to get relief / help with?

Method of Consumption

Would you like to learn about the benefits of vaporization and maximizing both the medicinal value while allowing your medicine to last longer.

Would you like to Pick up your things or have your items Delivery

Is there a local shop you would like to see @RoxiGray available at?

How can we be of an assistance?

Would like to take part in an education session on the who what when why and how of cannabis, ie RG101

Would you be interested our monthly subscription box?

Can we tag and Repost you in Social Media Posts?

            new client intake frm