Patients WelcomeRegistration form WelcomeRegistration form WelcomeYou need to register for pharmacy Clinical Cannabis Care if:Your doctor will send your prescription for medicinal cannabis oil to Clinical Cannabis Care directly;You file a paper prescription for medicinal cannabis oil at Clinical Cannabis Care; orYou wish to receive your medicinal cannabis oil at home by registered mail.If you have any questions, please do not hesitate to contact us. We are happy to help.Registration form 1 Personal information 2 Address details 3 Pharmacy details4 Medication 5 Data exchange 6 Payment details 7 Terms and Conditions GeslachtMrMiss/Ms/MrsInitials*Last name*Date of birth* Day Month Year Email address* Citizen Service Number (BSN)* Address* Street + house number City Postcode Phone number (fill in a daytime phone number)* Name of your pharmacy*Town/City where your pharmacy is located* Do you use medication?*YesNoState here which medication you use, preferably with your medication history*Do you take coumarin (anti-coagulants for which you are treated at the thrombosis centre)?*YesNowill you be notifying the thrombosis centre?Have you been (are you currently being) treated for schizophrenia or any other psychiatric disorder?*YesNoHave you been (are you currently being) treated for glaucoma?*YesNoAre you pregnant or breastfeeding?*YesNoAre you suffering from any other conditions?*YesNoAre you suffering from any other conditions?*State here which conditions you are suffering from. For example, asthma, epilepsy and heart problemsDo you have allergies?*YesNoAllergieën*State here if there are any medications that you have had an allergic reaction to in the past Do you give us permission to request your medication history at your previous pharmacy?*YesNoGegevens elektronisch uitwisselen?*Do you give us permission to make your data available for consultation to other care providers through the National Exchange Point as discussed in the brochure ‘Share medical information electronically?’ from the Association of Healthcare Providers for Healthcare Communication (Vereniging van Zorgaanbieders voor Zorgcommunicatie)? On www.vzvz.nl you can find more information regarding electronic exchange of medical data through the health care infrastructure.YesNo Your prescription will be sent by Clinical Cannabis Care by registered mail. The costs for the medicinal cannabis oil CANNOT be claimed on your health insurance. Select your desirable payment method:Direct debit Direct debit As soon as your prescription has been received by us it will be prepared for shipment IBAN direct debitI hereby give permission for Clinical Cannabis Care to automatically withdraw the costs of the medicinal cannabis oil from account number:Bank transfer Bank transfer Payment by transferring the amount. We will send you a payment request. As soon as we have received your payment, your order will be prepared for shipment. Terms and Conditions I agree with the general sales and payment terms & conditions This iframe contains the logic required to handle Ajax powered Gravity Forms.