Contact Us Contact Us Our protocols are designed to help with a number of different conditions. Since we only deal with patients in a one-on-one consultation setting, the information provided in the form below will help us give you a more personalized experience. All information you share with us is confidential and never shared outside of Constance Therapeutics. After submitting the form below, you will be contacted by a Patient Support Representative within 24 hours. We'll get you in contact with one of our Patient Support Representatives. Let's get started with some basic information to better help you.Are you a physician or a patient?*PhysicianPatient What is your name?* First Last What is your phone number?*Who are you inquiring for?*MyselfAnother PersonA Pet What is the patient's name?* First Last Is the patient a minor?*YesNoWhat is your relationship with the patient?SpouseParentChildRelativeFriendCaregiverPhysicianOther What is your pet's name?What type of pet do you have?*DogCatOtherWhat is the size of your pet?Small (up to 25 lbs)Medium (25 to 50 lbs)Large (50 lbs or more) Where are you located?*CaliforniaUSA (Outside CA)InternationalWhat is your level of cannabis experience?NoneSomewhat ExperiencedExperiencedDo you have a valid California Cannabis Recommendation?*YesNo Just a couple more questions so we can better target your needs.What is the medical condition you are inquiring about?AlzheimersAnxietyArthritisAutoimmune ConditionCancer - BladderCancer - BoneCancer - BrainCancer - BreastCancer - ColonCancer - EsophagealCancer - GlioblastomaCancer - LeukemiaCancer - LiverCancer - LungCancer - OtherCancer - OvarianCancer - PancreaticCancer - ProstateCancer - SkinCrohn's DiseaseDepressionDiabetesEpilepsyGastrointestinalHormonal / MenstrualInsomniaLyme DiseaseNeurodegenerativeOtherPainPTSDTell us a little about your condition: What is your name?* First Last What is your title?What is your phone number?*What is your parent hospital or affiliation?CityStateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces PacificCountryUnited StatesAfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabweYour submission is completely confidential and will only be used for the purposes of direct communication. Constance Therapeutics will not share or reveal your information to a third party. What is your specialty?How did you find out about us?AdvertisementColleagueConstanceCustomer EventEmployee ReferralGoogle AdWordsInternet SearchMDPartnerPatientPurchased ListResearch/PaperTrade ShowVIPWebinarWebsiteOtherWhat is your interest in cannabis?Your submission is completely confidential and will only be used for the purposes of direct communication. Constance Therapeutics will not share or reveal your information to a third party. Thank you for completing the informational portion of form. Please input your e-mail address so we may respond to your inquiry promptly.What is your e-mail address?* NameThis field is for validation purposes and should be left unchanged.