Information Request Form

If you believe you or a loved one may qualify to be treated with medical cannabis in the State of Florida, please provide us the information requested below and someone on our staff will get in touch with you. It is our mission to deliver the highest quality of care for medical cannabis in Florida.

Patients name:

Date of Birth:

Email:

Contact Phone:

Qualifying Condition: The patient has been diagnosed with the following debilitating medical condition by a qualified, licensed health care provider or mental health professional. This diagnosis is stated in the official clinical documentation that will be submitted to Wholistic ReLeaf.

Other Condition (if not listed above):

Zip Code:

Have You Heard About Us:

Other Source (if not listed above):

Want to know more? Download our informational guide on medical cannabis.