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Formulario de admisión del paciente

Before you start, please take a few minutes to read our HIPAA Notice of Privacy Practices HERE and return to this page when ready to continue (will open new window)

Responda todas las preguntas y presione ENVIAR en la parte inferior. Esta información se mantiene completamente privada.
Most people who assume their ID does not have their middle name or that it only has their middle initial end up being incorrect. Please check. Incorrect information creates delays in getting your card to you
Can you use Zoom for video calls?
Scroll to find year and select the year, then use arrow to select month, then the day

We're NOT talking about the USA. This is that geographical area which is bigger than a city and smaller than a state.

Note: All doctors and pharmacists will still be able to see cannabis purchases made at a medical dispensary IF they look for it.
This is important: Cannabis has been known to have a dangerous drug interaction with blood thinners. In most cases, it increases your chance of internal bleeding when you are on a blood thinner (aspirin doesn't count). If you are currently taking one, we will need permission from your doctor before you can be certified for medical cannabis.
Are you using a blood thinner?
Did you have any problems with cannabis last year?
Cosas legales - por favor lea y  reconocer
Have you ever driven while under the influence?
Más asuntos legales: lea y  reconocer
Have you had thoughts of hurting yourself over the last year?
Si actualmente siente tendencias suicidas, llame al 911 o visite este enlace aquí para la Línea Nacional de Prevención del Suicidio.
Have you had serious thoughts of harming others over the last year?
Si actualmente se siente homicida, llame al 911 o a la línea directa nacional de crisis (1-800-273-8255)  o visite este enlace aquí para , un sitio web dedicado  para ayudar a prevenir el asesinato.
Are you currently pregnant, trying to get pregnant or breastfeeding?
¡Este es un tema muy debatido! Hay pocos buenos datos disponibles sobre la seguridad del consumo de cannabis durante el embarazo o la lactancia. Desafortunadamente, hay datos que sugieren que no es seguro. Por esta razón, se recomienda que no se arriesgue y evite usarlo durante el embarazo o la lactancia.
Almost done! Please check below any symptoms you've had in the last 24 hours.
Do you ever see or hear things others don't? Cannabis can make hallucinations worse or trigger them in patients with psychosis who have never had them before. If you have a history of psychosis or hallucinations, we will need permission from your doctor before you can be approved.
Cosas legales finales - por favor lea y  reconocer
Haga clic aquí si desea obtener más información sobre los posibles efectos negativos del consumo de marihuana.  productos Hay muchos más recursos, pero este es un buen lugar para comenzar.
Hit this button to submit the form

Después de enviar, debe ser redirigido a un cuadro de arriba en el que falta la información requerida o ser redirigido a una página de agradecimiento. También recibirá un correo electrónico agradeciéndole el envío del formulario. Si no está seguro de si el formulario se envió con éxito o no, espere unos minutos y verifique todo su correo electrónico (incluido el correo no deseado) en busca del correo electrónico de agradecimiento. 

After you hit Submit, you should either be taken back to a box above that is missing required information or be redirected to a Thank You page. You will also get an email thanking you for submitting the form. If you are unsure whether or not the form was successfully submitted, wait a few minutes and check all of your email (including spam) for the "Thank You" email. 

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