Farmacann Use Orders


Patient's Name:  

Patient's DOB:   

30 capsules per pill card - Select product and quantity of pill cards per month:

Thrive (1:1 CBD/THC ratio) (1 capsule = 5mg CBD/5mg THC)
Relief  (2:1 CBD/THC ratio) (1 capsule = 6.6mg CBD/3.3mg THC)
Ultra    (20:1 CBD/THC ratio) (1 capsule = 20mg CBD/1mg THC)
Night  (Indica THC) (1 capsule = 3mg THC/2mg Melatonin)

Physician’s Name (print):
Physician’s Address (Street, City, Zip Code):
Physician’s phone number:
Physician’s CA License No.:
Date: January 24, 2021

Leave this empty:

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Signature Certificate
Document name: Farmacann Use Orders
lock iconUnique Document ID: cef02a750af3532b182d006ad6c39e1568bc9e5f
TimestampAudit
December 30, 2020 2:22 pm PSTFarmacann Use Orders Uploaded by David Coennen - customerservice@farmacann.com IP 73.66.191.127, 207.246.240.97