Make a Referral

Patient Referral

Clinic Referral

Patient Report Form - CBPM Concerns

Please fill out this form if you require assistance with an issue relating to CBPM's 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 help with issues relating to your medical care with any clinic or pharmacy.

Full Name*

Email Address*

Phone Number

Cannabis Clinic/Prescriber*

Issue Category (Please select *

Select one option

If you selected other, please give us some details

Date of Incident*

Location of Incident (Closest Town or City will suffice)*

Proof of Prescribed Status at date of Incident (within 6 months)*

Details*

Are You Happy to be Considered for Group Litigation?

Optional - skip if unsure

Are You Happy to Go Public About Your Incident

Optional - skip if unsure

Join our mailing list
See our privacy policy.

This site is protected by reCAPTCHA and the Google Privacy Policy and Terms of Service apply.

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

Join our mailing list
See our privacy policy.

This site is protected by reCAPTCHA and the Google Privacy Policy and Terms of Service apply.

07984045124
Mail us
- Name
  
  Email
  
  Telephone
  
  Subject
  
  Message
  
  Thank You
  
  Your Email has been sent to:
Our Address
- Patient Protect

Make a Referral

This website uses cookies