Assessment Form - AKOS BIO: Online Pharmacy

Age VerificationStep 1 of 5

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Are You older Than 18 *

Have you ever been diagnosed with Schizophrenia or Psychosis? *

Please tell us more about your condition *

First Name *

Last Name *

ID Number *

Height *

Weight *

Gender

Date Of Birth *

Patient Email *

Patient Password *

Confirm Password *

Do you have an existing section 21 form? Please it upload here.

Drop your file here or click here to upload You can upload up to 1 files

Address 1 *

Address 2

City *

Province *

Country *

Postal Code *

Declaration *

I certify that the above information is true and correct. Should I attend a virtual consultation with a prescribing doctor, I consent to this information being shared with that doctor. Furthermore, should the prescribing doctor recommend and/or prescribe medical cannabis products, I hereby give my consent for the doctor to complete and sign any required Section 21 documents on my behalf, as necessary for the application and approval process.

Declaration *

By proceeding, you will enter a telemedicine consultation with an independent medical practitioner experienced in the prescription of pharmaceutical cannabinoids. The practitioner is registered with the HPCSA and operates independently of AKOS Bio. Prescriptions for cannabinoids will only be issued if deemed in the best interest of the patient, in accordance with professional and ethical standards. Therefore, a consultation does not guarantee that cannabinoids will be prescribed.

Please list all your acute and/or chronic medical conditions *

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Please list all medications that you are currently taking as well as the associated dosage. *

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Patient Assessment