Submit a Report

Submit a Report

Patient Issue Report

Clinic Partnership Enquiry

Patient Report Form - Prescription Cannabis Concerns

Please fill out this form if you require assistance with an issue relating to your cannabis prescription and the wider public or private services. This might be an issue concerning police action, landlords/housing associations, employers or access to venues or services.

We will require some personal information, including proof of prescription at the time of the incident in question. All information is solely for our internal use in relation to your case, and will not be shared or distributed anywhere else.

Please be aware we cannot provide support on issues you are experiencing with your cannabis-prescribing clinic or cannabis-dispensing pharmacy.

Full Name*

Email Address*

Phone Number

Cannabis Clinic/Prescriber*

Issue Category (Please select *

Please select all that may apply

Date of Incident*

Location of Incident (Closest Town/City or County)*

Proof of Prescribed Status at date of Incident *

Please dubmit a copy of your most recent prescription PRIOR to the date of the incident you are reporting.

Details*

Are You Happy to be Considered for Group Litigation?

This enables us to group your case with other similar cases. You are only committing to being considered - we will contact you for further consent to include your report in any legal action.

Are You Happy to Go Public About Your Incident: *

We will never publish any of your details without further consent from yourself

Clicking enables us to contact your clinic in regard to your Patient Protect report.*

This is essential in order for us to be able to support your case.

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Please fill out the form below if you're interested in working with Patient Protect to better help your patients who are experiencing discrimination for using medicinal cannabis

Full Name*

Email Address*

Clinic Name*

Your Message

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