Membership Application

At Pantera Rosa, we are dedicated to promoting holistic wellness and responsible cannabis use. To ensure that we maintain a safe and enriching environment for all members, we have a thorough application process. Please fill out the form below with accurate and honest information. Your responses will help us understand your needs and how we can best support your wellness journey.

Personal Information

Full Name *

Please enter your full name!

Date of Birth *

Please enter your date of birth!

ID Number *

Please enter your national ID number!

ID Issue Date *

Please enter your national ID issue date!

ID Expiry Date *

Please enter your national ID expiry date!

Mobile Phone Number *

Please enter your mobile phone number!

Email *

Please enter your email address!

Country *

Please select your country of residence!

Address *

Please enter your address of residence!

ID Front

Please upload a photo of your national ID!

ID Back

Please upload a photo of your national ID!

Utility Bill

Please upload a photo of your utility bill!

Health and Wellness Profile

Do you have any medical conditions that you are currently managing? *

Yes

Please indicate if you have any medical conditions!

Are you currently taking any medications? *

Yes

Please indicate if you are taking any medication!

How long have you been using cannabis for wellness purposes? *

Less than 6 months

6 months to 1 year

1 to 3 years

Over 3 years

Please indicate how long you've been using cannabis!

What are your primary reasons for using cannabis? (Select all that apply) *

Pain management

Anxiety or stress relief

Sleep aid

Recreational use

Other

Please indicate primary reason you are using cannabis!

How frequently do you use cannabis? *

Daily

Several times a week

Once a week

Less than once a week

Please indicate the frequency you are using cannabis!

What methods of consumption do you typically use? (Select all that apply) *

Smoking

Vaping

Edibles

Tinctures

Topicals

Other

Please indicate the methods of consumption you typically use!

Do you have any allergies or sensitivities that we should be aware of? *

Yes

Please indicate if you have any allergies or sensitivities!

Have you experienced any adverse effects from using cannabis? *

Yes

Please indicate if you have experienced any adverse effects from using cannabis!

What are your wellness goals as a member of Pantera Rosa? (Select all that apply) *

Improve overall health

Manage a specific condition

Learn more about cannabis

Connect with a supportive community

Other

Please indicate what are your wellness goals as a member of Pantera Rosa!

Is there any additional information you would like to share with us about your health and wellness?

Invitation Information

Referring Member *

Please enter the name of the member that referred you!

Invitation Code *

Please enter your invitation code!

I have read and agree to the Terms & Conditions

Please read and agree to the Terms & Conditions!

Membership Application

Personal Information

Health and Wellness Profile

Invitation Information

Services

Membership

Support