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Email*

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Password*

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(at least 6 characters)

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Who are you signing up today?*



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Enter your pet's information where you see "Client". For instance, enter your pet's name in the field asking for Client Name.




How did you hear about us?*

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Please tell us where you heard about us.*

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Recipient of Confidential Information (parent/legal guardian/caregiver) *

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Client First Name*

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Client Last Name

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Weight (in lbs)*

Please enter the weight to the nearest pound..

Diagnosis*

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Date of Diagnosis

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Year of Birth*

Please enter the four digit birth year, yyyy. For example, 2001.

What symptoms would you like to use CBD for?

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Does the client have:






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If seizure disorder diagnosis, please select all seizure types that apply:












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If you are willing to be contacted by other families with the same or similar diagnosis, which contact information of yours may we share with them?

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Has the client used therapeutic cannabis in the past? If so, please specify:

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It is recommended that you be followed by an attending physician. Who is your healthcare practitioner?

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Practitioner Contact Info (We will not contact them on your behalf. We may contact them with general cannabinoid science information)

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What is their field of study? (ie: oncologist, neurologist)

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Known allergies?

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Current medications and dosages?

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Street Address*

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Street Address 2

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City*

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State / Province*

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Zip Code / Postal Code*

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Country*

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Phone Number*

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Phone Type*

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We may send occasional texts to inform you about RoC events or important happenings in the cannabis/hemp world. We strive to make these infrequent messages meaningful. By supplying your mobile number, you agree to accept text messages from RoC. Standard text rates may apply. Check the box below to opt-out.

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What RoC programs and services are most valuable to you? (Select 3)










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What would you be interested in seeing from RoC?







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You have another great idea? Please tell us all about it!

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In a typical year, how much do you donate to charitable organizations?






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The Realm of Caring Foundation does not give or substitute for medical advice. It is important that you remain under a physician’s care. Your privacy is one of our highest concerns. Please read through our Privacy Policy to understand how we collect and use your data.

Mutual Hold Harmless: Each party shall defend any third party claim against the other party arising from the death of or physical injury to any person or damage to the indemnified party's property to the extent proximately caused by the negligence of the indemnifying party or its agents or employees, and indemnify and hold harmless the other party and its respective officers, directors and employees from and against damages, liabilities and reasonable costs and expenses, including reasonable legal fees incurred in connection therewith.




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