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Do You Have Any Drug Allergies? *
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Last 4 Digits of Social Security # *
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Qualifying Conditions *
Please enter the condition(s) in which you seek Medical Marijuana for.
Review of Symptoms *
Please enter the symptom(s) that you have.
Surgical History: Please list any surgeries and date of such surgery.
Describe non-surgical treatments you have received/are receiving for your medical condition(s) for which you seek a recommendation of medical marijuana: *
Are you currently receiving treatment for the condition(s) that you are being evaluated for medical marijuana? *
History of mental illness in your immediate family: parents, grandparents, or siblings? *
Please let us know of any activities that are substantially limited or impaired (i.e. pain/weakness/impaired strength or ability) by the medical condition for which you seek medical marijuana:
Have you used cannabis in the past to treat your medical condition? *
Do you have a history of substance abuse or addictions? *
Do you smoke tobacco? *
Preferred method of marijuana use as a medicine: *
You may select multiple options.
You do understand that smoking is harmful to your lungs and is not medically advised? *
Have you had any negative/adverse reactions from cannabis use? *
Additional Information that you consider relevant to the physician’s evaluation:
Are there medical records that document your medical condition(s)? *
Records Release Request *
HIPAA Patient Consent Form *
Informed Consent for Treatment with Medical Cannabis *
Practice Consents *
Digital Signature *
By electronically signing this form, I declare under penalty of perjury that the information on this form is true and correct to the best of my knowledge and understand that the typed electronic signature shall have the same legal effect as an original signature.
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