Owner’s Information

Name *

First

Last

Email *

Username *

Password *

Password

Confirm Password

Address *

Address Line 1

City

State / Province / RegionAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingState

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 *

MM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY20232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920

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? *

Signup

Thank you so much for using Genie’s Pack Sign-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.