LOG IN
Local:
(269) 327-0033
Toll Free:
(877) 774-8757
Fax:
(269) 327-2709
info@centerforcompounds.com
Who We Are
Our Staff
Accreditation
Compounding
Compounding Solutions
RX Refills
Consultation Services
Compounded Hormone Therapy
Foreign Travel & Immunizations
Pain Management
Veterinary Needs
Hospice Needs
CBD
Contact Us
FAQ
Who We Are
Our Staff
Accreditation
Compounding
Compounding Solutions
RX Refills
Consultation Services
Compounded Hormone Therapy
Foreign Travel & Immunizations
Pain Management
Veterinary Needs
Hospice Needs
CBD
Contact Us
FAQ
CBD Consult Request
CBD Consult Request
CBD CONSULT REQUEST
Date:
(Required)
MM slash DD slash YYYY
Demographic Information:
First Name
(Required)
Last Name
(Required)
Date of Birth:
Address:
Name of pet:
(If you are inquiring for an animal friend)
Type of pet:
Person of contact:
(If you are inquiring about CBD on behalf of someone, other than yourself, please list your name. Let us know your preferred contact method listed below)
Relationship to person interested in CBD:
Self
Spouse
Parent/Guardian
Pet parent
Family member
Friend
Prefer not to say
Other
Email:
Telephone:
(Required)
Best time of Day to be Reached:
(Required)
Morning (8:30 AM-11:30 AM)
Afternoon (12 PM-5:00 PM)
No Preference
(Please note that requests can take up to 48 hours to complete)
Preferred Contact Method:
(Required)
Telephone
Email
No Preference
Provider Information:
Name of Office/Clinic:
Primary Care Provider:
Office/Clinic telephone:
Referred by:
Medical Provider:
Friend/Family:
Online/Local Ad:
Other:
Name of reference (if applicable):
Current Medication List:
Add
Remove
(Please list name of medication and frequency of use. This will allow us to check for interactions with CBD. To add multiple medications click the plus symbol.)
Allergies:
Add
Remove
(examples: Medication, food, etc. To add multiple allergies click the plus symbol.)
Pain Management (if applicable):
How often do you experience pain?
Very Frequent (Multiple days per week)
Less Frequent (Multiple days per month)
Sporadic (On occasion)
Other
Rate Pain: (1 being least severe, 10 being most severe)
Please enter a number from
1
to
10
.
Where are you experiencing pain?
Type of Pain: (nerve, muscle, soft tissue,etc. if known)
Does your pain come and go or is it constant?
Is your pain better or worse during certain parts of the Day/Night?
Have you been diagnosed or know the source of pain?
What makes your pain worse?
(examples: increased level of activities, weather, medical procedures, etc)
What makes your pain better?
(examples: medications, otc or prescribed, hot/cold therapy, rest, etc)
Sleep Management (if applicable):
How often do you experience difficulty sleeping?
Very Frequent (Almost every night)
Less Frequent (Several nights per month)
Sporadic (On occasion)
Other
Do you have trouble falling or staying asleep?
What else have you tried for improved sleep?
(examples: otc/prescribed sleep aides, change in sleep patterns, change in activity before bed, etc)
How long have you had trouble sleeping?:
Anxiety Management (if applicable):
How often do you experience anxiety?
Very Frequent (Multiple days per week)
Less Frequent (Multiple days per month)
Sporadic (On occasion)
What makes you anxious?
Does your anxiety come and go?
What else have you taken for anxiety?
(examples: otc/prescribed medication, etc)
What makes your anxiety better?
(examples: medication, exercise, certain activities, etc)
What makes your anxiety worse?
(examples: medication, behavioral changes, life events, etc)
You may list additional concerns/requests:
Some CBD products contain 0.3% or less THC and very rarely can show up on a drug screen. Is this a concern for you?
Yes
No
Not sure
If CBD is appropriate for your clinical concern(s), do you prefer the following:
Oral Capsules
Sublingual Liquid
Gummies
Topical Formulations
Not sure
Looking for recommendation
Preference for Vegan or Non-GMO products?
Yes
No
No Preference
We also consult with pet parents regarding their pets pain or anxiety. Would you like to discuss pet CBD products that may help these conditions?
Yes
Not at this time
These statements have not been evaluated by the Food and Drug Administration. Our CBD products are not intended to treat, cure or prevent any disease
