Intake Form | Athena Heals Medical Marijuana Cards

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Patient Intake Form

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)

Please answer all questions and hit SUBMIT at the bottom. This information is kept completely private.

First Name (as appears on ID)*

Middle Name (or initial) - only if it's on your ID and exactly as your ID

Email - same as appointment*

Phone*

Date of Birth*

Height

Scroll to find year and select the year, then use arrow to select month, then the day

Weight

I understand that anyone under 21 will require the 30 minute "Special Needs" appointment and medical clearance from their doctor.

Last Name (as appears on ID)*

Can you use Zoom for video calls?

Yes Zoom is fine

No I'd like to use another app

For video calls I prefer to use

Do you have a preferred pronoun?

Mailing Address

What county do you live in?

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

How did you hear about me?

If you refer someone to me where would you like the $10 to go?

I am a Parent or Legal Guardian of the applicant

I understand I need to schedule the 30 minute "Special Needs" appointment instead of the $90 appointment.

Parent's/Guardian's Full Legal Name on ID - if there are 2 parents, list both

Parent/Guradian's birthday, email, and full address as on ID

I want to add a Registered Agent who can pick up products for me

I understand I need to schedule the 30 minute "Special Needs" appointment instead of the $90 appointment.

Registered Agent's Full Legal Name as on ID

Registered Agent's birthday, email, and full address as on ID

Name of prescribing provider or therapist

Keep this visit private for now

Send record of visit to my provider

Note: All doctors and pharmacists will still be able to see cannabis purchases made at a medical dispensary IF they look for it.

Provider Mailing Address

Medical conditions for which you seek cannabis

Please note, anyone with Bipolar Disorder or Schizophrenia will need permission from their doctor to get a medical card. We will help you talk to your doctor about it.

Past non-cannabis treatments tried

Include everything not cannabis you can think of, especially names of prescriptions.
You won't qualify if you put none or N/A.

Why do you want to swtch to or add cannabis?

Other medical conditions

List any drug allergies

If you take any medications for anything, please list them below

Current Medication Name

Dose

Frequency

I have another medication

Current Medication Name

Dose

Frequency

I have another medication

Current Medication Name

Dose

Frequency

I have another medication

Current Medication Name

Dose

Frequency

I have another medication

Current Medication Name

Dose

Frequency

I have another medication

Current Medication Name

Dose

Frequency

I have another medication

List other medications if you have more

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?

Yes I'm on a blood thinner

No, I'm not on a blood thinner

Have you used marijuana products before?

Yes I am familiar with it

No I have never tried it before

Please describe your current usage

Check here if you have ever had a bad reaction to marijuana

Please describe what bad reactions you have had

Have you had a medical marijuana card before?

No I have never had a medical card before

Yes I have had a medical card before

Where have you had medical marijuana cards before?

Do you ever use alcohol?

Yes

No, never

Not anymore

Please list any illegal substance you use and how often

If you have ever suffered addictions of any kind, please describe here.

Legal Stuff - please read and acknowledge *

I acknowledge that marijuana is considered to be addicting and I accept full responsibility if I become addicted to any marijuana products I use with my medical marijuana card. I also understand that marijuana use is believed by some to lead to abuse of other addicting substances and I take full responsibility for any other substances I might use. (If you see big blank spots, keep scrolling down - computers are a mystery sometimes!)

Have you ever driven while under the influence?

Yes I have driven under the influence in the past

No I have never driven under the influence

If you currently feel suicidal, please call 988 or visit this link here for the National Suicide Prevention Lifeline

Do you ever have serious thoughts of harming others?

Yes, I have seriously wanted to hurt people before

No, I have never seriously wanted to hurt anyone

If you currently feel homicidal, please call 911 or the National Crisis Hotline (1-800-273-8255) or visit this link here for SAVINGCAIN.org, a website dedicated to helping prevent murder.

Are you currently pregnant, trying to get pregnant or breastfeeding?

Yes

N/A

This is a hotly debated issue! Limited good data is available for the safety of cannabis use while pregnant or breastfeeding. Unfortunately there is data that suggests it is not safe. For this reason, it is recommended that you not take the risk and that you should avoid using it while pregnant or breastfeeding.

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.

Yes I have had hallucinations

No I have not had hallucinations

I have a history of psychosis without hallucinations

Use this space to add anything or explain in more detail if needed

Final Legal Stuff - please read and acknowledge *

I acknowledge that marijuana and cannabis products may have negative side effects. This includes possibly causing short and/or long term damage to my mind and body or even causing a severe allergic reaction. I take full responsibility to learn as much as I can about the risks in order to make an informed decision before using it. I also understand that future research may show other positive and negative effects. Neither I nor my family may hold Athena Heals LLC nor any agent of Athena Heals LLC liable for any negative effects (including my death) that may result from my using marijuana or cannabis products.

Click here if you would like to learn more about the potential negative effects of using marijuana products. There are many more resources, but this is a good place to start.

Please type your name below and hit submit. This will serve as a digital signature confirming you are the person filling out this form, that you have read everything above, and that you have read, undertood and agree to the items noted in our HIPAA Notice of Privacy Practices

Hit this button to submit the form

PLEASE NOTE: Filling out this form is not the same as making an appointment. If you haven't made an appointment yet, please be sure to do that after you finish this form. You can do that on the Services page or click here (don't worry, clicking this will open a new window).

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, STAY ON THIS PAGE and wait a few minutes to check all of your email (including spam) for the "Thank You" email. But your main proof that it is submitted is that you will be taken to a new page.

This is the end of the form. Please hit the Submit button above. Please do NOT fill out the green contact form below unless you have a special question.

VIRGINIA

Patient Intake Form

Please answer all questions and hit SUBMIT at the bottom. This information is kept completely private.

Scroll to find year and select the year, then use arrow to select month, then the day

Note: All doctors and pharmacists will still be able to see cannabis purchases made at a medical dispensary IF they look for it.

Include everything not cannabis you can think of, especially names of prescriptions.
You won't qualify if you put none or N/A.

Legal Stuff - please read and acknowledge *

More Legal Stuff - please read and acknowledge *

If you currently feel suicidal, please call 988 or visit this link here for the National Suicide Prevention Lifeline

If you currently feel homicidal, please call 911 or the National Crisis Hotline (1-800-273-8255) or visit this link here for SAVINGCAIN.org, a website dedicated to helping prevent murder.

Final Legal Stuff - please read and acknowledge *

Click here if you would like to learn more about the potential negative effects of using marijuana products. There are many more resources, but this is a good place to start.

Hit this button to submit the form

Patient Intake Form

Please answer all questions and hit SUBMIT at the bottom. This information is kept completely private.

Scroll to find year and select the year, then use arrow to select month, then the day

Note: All doctors and pharmacists will still be able to see cannabis purchases made at a medical dispensary IF they look for it.

Include everything not cannabis you can think of, especially names of prescriptions. You won't qualify if you put none or N/A.

Legal Stuff - please read and acknowledge *

More Legal Stuff - please read and acknowledge *

If you currently feel suicidal, please call 988 or visit this link here for the National Suicide Prevention Lifeline

If you currently feel homicidal, please call 911 or the National Crisis Hotline (1-800-273-8255) or visit this link here for SAVINGCAIN.org, a website dedicated to helping prevent murder.

Final Legal Stuff - please read and acknowledge *

Click here if you would like to learn more about the potential negative effects of using marijuana products. There are many more resources, but this is a good place to start.

Hit this button to submit the form

Include everything not cannabis you can think of, especially names of prescriptions.
You won't qualify if you put none or N/A.