Sign up for Genie's Therapeutics Concierge Program

Owner's Information

Name *

First

Last

Email *

Username *

Password *

Password

Confirm Password

Address *

Address Line 1

City

State

Zip Code

Phone

Checkbox

By checking this box you give Genie's permission to text/call the above number (allows quicker contact from our Veterinarian Cannabis Counselors)

Dog's Information

Name of your canine companion

Dog Breed

Your Dog's birthday *//

Dog's weight *

Please upload a picture of your furry best friend (We love seeing the pups we are helping!!)

Click or drag a file to this area to upload.

Checkboxes

By checking this you give Genie's Therapeutics permission to use your picture on social media

Purchase Information

Date of Purchase *

Where did you purchase your Genie's Hemp Signature Blend (Please be specific) *

What was the reason for your purchase? *

Thank you so much for signing up. One of our Veterinary Cannabis Counselors (VCCs) will reach out to you shortly. Of course, you may always Contact Us with any questions you may have.