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First-Time Request
Full Name:
Email Address:
Contact Number:
Preferred Method of Contact:
Phone Call
WhatsApp
Text Message
Email
Age Verification:
I am 21 years old or older.
Nationality:
Country of Residence:
Duration of Stay in Cape Town:
Have you used cannabis before?
Yes.
No.
Do you have a medical prescription or patient card for cannabis?
Yes.
No.
Do you need a consultation with a prescribing doctor?
Yes.
No.
What is your primary reason(s) for using cannabis? (Check all that apply)
Anxiety
Cancer
Weight Loss & Weakness
Glaucoma
Crohn's Disease
Joint Pain
Sleep
Multiple Sclerosis
Muscle Pain
Nausea
Seizures / Epilepsy
Socializing
Other (Please specify)
Preferred method of consumption:
Edibles
Flowers
Concentrates
Vaping
Topicals
Tinctures
Capsules
Unsure
Preferred strain type:
High THC
High CBD
Balanced THC/CBD
Unsure
Preferred quality type:
Outdoor
Greenhouse
Indoor
Unsure
Product Preference:
Licensed Products Only
Non-Licensed Premium Products from Local Growers
No Preference
Any health conditions or medications we should be aware of?
Preferred location for the experience:
Home Delivery
Guided Experience at a Safe Location
Any additional notes or preferences?
Send
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