Consultation Form - CannaboxMD

Personal Information

First Name *

Please enter your first name

Last Name *

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Date of Birth *

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Gender *

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Nationality *

Please select your nationality

Line ID

ID/Passport Number *

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Phone Number *

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Email Address *

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Current Address / Document Recipient Address *

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Drug Allergies (If Any)

Upload ID/Passport *

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Cannabis Experience

Have you used cannabis before?

Preferred consumption method

Treatment Goals

What are your main treatment goals?

Pain Relief

Better Sleep

Reduce Anxiety

Improve Appetite

Essential Access 🟢 500 THB

✔ Medical Prescription
✔ Valid for 30 days ⏱
✔ Use at 1 dispensary 🏥
✔ PDF copy included 🧾

Prescription + Certificate 🔸 750 THB

Tap to expand

✔ Medical Prescription
✔ Medical Certificate
✔ PDF copies 🧾
✔ 15% discount at partnered clinics 🏥
✔ Valid for 30 days ⏱
✔ Use at 1 dispensary 🏥

All-In-One Care 🔹 1500 THB

Tap to expand

✔ Medical Prescription
✔ Medical Certificate
✔ Physical Medical Card 💳
✔ PDF copies 🧾
✔ 15% discount at partnered clinics 🏥
✔ Valid for 30 days ⏱
✔ Use at 1 dispensary 🏥

Payment Information

Selected Package:

Bank Transfer Details

Bank: Kasikorn Bank

Account Name: Cannabox Company Limited

Account Number: 152-3-80737-0

Amount: THB

QR Code Payment

After payment, please upload your payment slip:

🧾

Click to upload payment slip