Clinical Trial Intake Form

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1. Tell us about yourself. Please note that at present, Humboldt Green Research is only performing research in California.
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2. How did you hear about Humboldt Green Research?
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3. Would you be willing to participate in “double-blind” clinical trials where you would be asked to evaluate the effectiveness of different strains of cannabis?
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4. Are you a “California 215 Patient” with a doctor's recommendation?
5. If you are a 215 patient, please enter your "215 doctors" contact information
6. If you are not a current California 215 patient, but you do have a qualifying medical need, Humboldt Green Research may help you get a 215 recommendation. Would you like to apply for this service?
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7. How much Cannabis do you use per month?
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8. How much Cannabis would you use per month if it were 1/2 price?
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9. What is the primary medical reason you use Cannabis?
10. Are there any specific strains that you have found to be particularly effective for this use? Please list all
11. Are there any specific strains that you have found to be particularly ineffective for this use? Please list all
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12. Do you prefer
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13. Do you prefer Cannabis grown
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14. Do you prefer Cannabis grown
15. Humboldt Green Research has various programs to help low-income participants afford their Medicine. Do you think you would like to apply for low income cost subsidies?

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16. How much more would you pay for Cannabis that is certified organic?
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17. How much more would you pay for Cannabis that had an official sticker showing taxes were paid in Humboldt County California?

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18. Would you be willing to pay for your medicine electronically using a credit card or PayPal account?
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19. Would you be willing to attend public events to voice your support for Humboldt Green Research?
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20. Would you be willing to appear in one or more documentaries being filmed about our research?
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