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Medical Marijuana Cards logo_edited_edit
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.
Can you use Zoom for video calls?
Scroll to find year and select the year, then use arrow to select month, then the day

I'm 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.

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.

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

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

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?
Have you used marijuana products before?
Have you had a medical marijuana card before?
Do you ever 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 hurting yourself
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?
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?
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'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.
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

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.

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