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Patient Intake
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New Patient Cannabis
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Renewal
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Emotional Support Animal
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Date of Birth
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Phone Number
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Full Address
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County
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Phone Number
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Email Address
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Social Security Number
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How did you hear about us?
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Marital Status
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At some point if we are able to provide follow up opportunities via telemedicine, would you have an interest?
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Medical History
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Are you Pregnant or Nursing?
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Height
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Weight
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Medical History
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Are you currently taking any medications?
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If yes, please list them:
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Do you have any allergies?
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If yes, please list them:
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Smoking History
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Alcohol History
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Trauma/Abuse History (check all that apply)
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In you lifetimes, have you ever tried/used Marijuana?
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Has another physician placed you on the state's Medical Marijuana Use Registry so you can apply for the Medical Marijuana Card?
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If yes, what is the physicians name:
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Do you use online scheduling?
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Anything special we need to know
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