Patient Intake Form
Please answer all questions and hit SUBMIT at the bottom. This information is kept completely private.
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
Do you ever have thoughts of harming yourself?
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 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.