Patient Intake Form

Contact Information

Phone numbers must be in (XXX) XXX-XXXX format.

Phone numbers must be in (XXX) XXX-XXXX format.

Email Address must be in your@email.com format.

Patient Information

Identification Documents

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Emergency Contact

Phone numbers must be in (XXX) XXX-XXXX format.

Primary Care Physician

Phone numbers must be in (XXX) XXX-XXXX format.

Guardian Information
If the patient is a minor, please fill out the following information.

Phone numbers must be in (XXX) XXX-XXXX format.

Phone numbers must be in (XXX) XXX-XXXX format.

Phone numbers must be in (XXX) XXX-XXXX format.

Current Condition
If known, please tell us which condition are you currently seeking treatment for.

Additional Questions

Patient-Pharmacist Counseling Declination and Waiver

As a patient you have the right to waive an optional consultation. If you do not waive by selecting “yes” and signing below, you will need to book an appointment here before visiting or ordering online.

I, the undersigned, am a qualifying patient for the use of cannabis products, as defined in §54.1-3408.3 of the Code of Virginia. As part of my visit to Beyond Hello Virginia, a registered pharmaceutical processor and cannabis dispensing facility, I was offered counseling with a Beyond Hello Virginia pharmacist. I have declined and refused such pharmacist consultation.

I acknowledge that I have received, or will receive following dispensing, written information from Beyond Hello Virginia that provides me important information relating to safe techniques for proper use and storage of cannabis products and for disposal of the products in a manner that renders them nonrecoverable.

Nonetheless, I understand that my refusal to receive individualized pharmacist counselling may increase the risks associated with the use of cannabis dispensed by Beyond Hello Virginia. I assume the foreseeable and unforeseeable risks of adverse events related to the administration, use and disposal of cannabis, and agree to release, discharge and hold harmless Beyond Hello Virginia, its affiliates and its employees free from any and all liabilities, claims, cause of action, damages, or losses, which may be incurred by the undersigned in administering, using and disposing of cannabis without such rejected patient counseling.

This declination and waiver herein shall remain in effect until I explicitly request counseling from Beyond Hello Virginia pharmacists, who remain available upon my request. I acknowledge that Beyond Hello Virginia will offer me counseling again prior to any future dispensing.



Signature