Stream Dream Web
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Membership Form
You are one step closer to being an exclusive client of Stream Dream Web. Please fill out the form below in its entirety and click the submit button. Once all of your documentation is completed and received you can begin ordering our Cannabis products by any of our 3 delivery methods. If you are unsure how to answer any of the questions, please do not hesitate to call or email us.
Name:
Address:
City:
Province:
Postal Code:
Email:
Phone Number:
Date of Birth:
MMAR or MMPR #:
Medical Conditions:
Physicians Name:
Address:
Postal Code:
City
Province:
Are you currently taking prescription medication (yes or no)?:
If yes, please describe:
How long have you been using cannabis?:
How does Cannabis affect your symptoms?:
How often do you used Cannabis?:
Does this dosage alleviate your symptoms?:
I herby declare that all of the above stated information is factual.
Applicant's Printed Name:
Date:
Applicant's Signature (if applying online Applicants Inititals):
