Intake Form | Athena Heals LLC

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

Last Name (as appears on ID)*

Email - same as appointment*

Phone*

Date of Birth*

Height

Weight

Preferred video app if not Zoom

Click on year, scroll and select year, then pick month, then pick day last

ID/Driver's license State

ID/Driver's license number

We ask because it is required on the certificate. If you are a parent and your child does not yet have an ID, use your number.

Preferred pronoun?

I am a Parent or Legal Guardian of the applicant

Parent's/Guardian's Full Legal Name on ID

I want to add a Registered Agent

Registered Agent's Full Legal Name as on ID

How did you hear about me?

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

Mailing Address

List any drug allergies

Name of prescribing provider or therapist

Keep this visit private for now

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

Send record of visit to my provider

Provider Mailing Address

Medical conditions for which you seek cannabis

Past non-cannabis treatments tried

Include everything you can think of, especially names of prescriptions. Please don't put none or N/A.

Other medical conditions

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 needed

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. If you are currently taking one, we will need to discuss it 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

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?

Yes

Where have you had medical marijuana cards before?

Do you use alcohol?

Yes

Please list any other 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.

Have you ever driven while under the influence?

Yes

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

Do you ever have serious thought 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.

If you are female, are you currently pregnant, trying to get pregnant or breastfeeding?

Yes

Not applicable

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.

Fever

Palipatations/heart racing

Chills

Cough

Headache

Anxiety

Depression

Euphoria

Difficulty breathing

Nausea/Vomiting

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, we will need to discuss this before you can be approved.

Yes

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.

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 email your certificate to you. I also email you instructions, your renewal reminders, medical check-ins, and extremely rare newsletters only with information I feel is important for you to know. Your email address is Federally Protected HIPAA information - it is illegal for me to share or sell it to anyone.

Thanks! Please remember to complete the last step below and hit Submit. It's not done until you see for the page that says Thank You. Then check your email to verify the address.

Keep scrolling! There's more below....

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 successfully submit the 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, wait a few minutes and check all of your email (including spam) for the "thank you" email.

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.

Click on year, scroll and select year, then pick month, then pick day last

We ask because it is required on the certificate. If you are a parent and your child does not yet have an ID, use your number.

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 you can think of, especially names of prescriptions. Please don't put none or N/A.

Have you used marijuana products before?

Have you had a medical marijuana card before?

Do you use alcohol?

Legal Stuff - please read and acknowledge *

Have you ever driven while under the influence?

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.

If you are female, are you currently pregnant, trying to get 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? 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, we will need to discuss this before you can be approved.

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.

Keep scrolling! There's more below....

Hit this button to submit the form