Patient Intake Form
Please answer all questions and hit SUBMIT at the bottom. This information is kept completely private.
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NOTE: Bare Bones appointment requires Zoom
Have you used marijuana products before?
Have you had a medical marijuana card before?
Do you use alcohol?
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Legal Stuff - please read and acknowledge
Have you ever driven while under the influence?
More Legal Stuff - please read and acknowledge
Do you ever have thoughts of harming yourself?
If you currently feel suicidal, please call 911 or visit this link here for the National Suicide Prevention Lifeline
Do you ever have serious thoughts of harming others?
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.
If you are female, are you currently pregnant, trying to get pregnant or breastfeeding?
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.
Almost done! Please check below any symptoms you're having right now.
Do you ever see or hear things others don't?
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.

To ensure you receive all notifications from me, please re-enter your email address below and hit Subscribe. Because typos are so common, you will receive an email asking you to verify the address. This gives me permission to send emails that will include instructions, your certificate, your renewal reminder, medical check-ins, and extremely rare newsletters. Your email address is Federally Protected HIPAA information - it is illegal for me to share or sell it to anyone.

Thanks! Please complete the last step below, hit Submit, then check your email to verify the address.

After you 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.