MEDICAL CANNABIS

REGISTER ONLINE

Submit the form below to get un-Restricted dispensary access. After submitting this form, you can login and purchase without restriction. The medical team reviews all orders prior to fulfillment.

NEW REGISTRATION

First Name*

Last Name*

Nationality*

Age*

DECLINED : I'm sorry, you must be at least 20 years of age to access the un-Restricted dispensary. Any orders placed on this registration will NOT be fulfilled.

Gender*

Male Female

Height cm*

Weight kg*

Email Address*

Thai Phone Number*

ID Upload* Passport ID or Driver's License, etc. Max 1 File Size 5MB or Less

Upload Identification

What are your main health problems?*

How do you currently treat these problems?*

Do you take medicine everyday?*

Yes No

Please List All Current Medications*

Do you have Food or Drug Allergy?*

Yes No

Please List All Food and Drug Allergies*

Are you pregnant or plan to be?*

Yes No

DECLINED : I'm sorry, pregnant women or women planning pregnancy can NOT access the un-Restricted dispensary. Any orders placed on this registration will NOT be fulfilled.

Medical Reports (optional) Max 5 Files Size 5MB or Less per File

Upload Medical Reports (optional)

I have provided accurate information and confirm all information to be true. I hereby authorize FRESH MEDIQ to receive all the information I have disclosed in this form.*

*Write Your Signature

Create Password*

Confirm Password*