Patient Intake Form

Full Legal Name

Home Phone

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

Cell Phone
By entering your number, you agree to receive mobile messages from our patient management platform, ArfinnMed. Message frequency varies. Message and data rates may apply. View our Privacy Policy and SMS Terms.

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

Email Address

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

Address

Address Line 2

City

State

ZIP Code

County

Sex

Gender

Specify Gender

Your Date of Birth (DOB)

Weight (lbs)

Height (feet)

Height (inches)

Patient Registry Number (optional)

Drivers License #

Drivers License Issued State

Drivers License Photo Upload (.jpg, .png, .gif, .jpeg)

Emergency Contact Name

Emergency Contact Phone #

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

Primary Care Physician Name

Primary Care Physician Phone #

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

Father's Name

Father's Phone #

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

Mother's Name

Mother's Phone #

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

Caregiver's Name

Caregiver's Phone #

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

Are you currently using Delta 9 THC? *

If yes, what is your tolerance?

Do you want Delta 8 THC in your formulation? Delta 8 THC doesn't require a medical card license and is legal in all 50 states. Delta 8 THC is 50-70% less potent that Delta 9 THC (Federally Illegal), but 10 times more medical. Please ask us any questions or concerns regarding Delta 8 THC. Checking "Yes" below does require the use of Delta 8 THC, but the consent is required before we supply it. *

PLEASE COMPLETE IF YOU DECIDE TO USE DELTA 8 THC:

I agree, if I decide to use Delta 8 THC, that I will test positive for a THC Drug Test.

I understand that UWD nor ECS Alchemy LLC are not implying or suggesting that medical cannabis should be a substitute for any other treatment prescribed by another physician.

Delta 8 THC is not regulated by the USFDA and therefore may contain unknown quantities of active ingredients, impurities and/or containments.

I am aware that a notice of compliance has not been issued under the Food and Drug Administration’s regulations concerning the safety and effectiveness of marijuana as a drug. I understand the significance of this fact.

I understand the benefits and risks associated with the use of Delta 8 THC are not fully under- stood and that the use of marijuana may involve risks that have not been identified. I accept such risk.

I agree that if I am a female patient that I will contact my attending physician if I become or think about becoming pregnant. I acknowledge that the use of medical marijuana creates pass- through problems to a fetus during pregnancy and to a baby during breastfeeding.

I should not drive a vehicle while using medical marijuana and that I can get a DUI for driving under the influence.

Do you consent?

Please write your signature in the box below

Patient Intake Form

Contact Information

Patient Information

Identification Documents

Emergency Contact

Primary Care Physician

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

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

Additional Questions

Signature

Patient Intake Form

Contact Information

Patient Information

Identification Documents

Emergency Contact

Primary Care Physician

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

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

Additional Questions

Signature

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

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