Let's get started with some simple questions...
First Name: *

Last Name: *

Phone Number *

Postal Code: *

Date of Birth

Tell us why you think you're a good candidate for Medical Cannabis? *

Example: ADHD, Insomnia, Anxiety, Past Trauma, etc
Do you have documentation for your medical condition?

If no we may be able to assist
Where did you first see Campana Care? *

Thanks for filling out the form. We'll be contacting you soon.
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