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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.
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.
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?
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 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 thought 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, 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? 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.

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....
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.

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