Patient Intake Form
Enter your information below for your appointment with Medical Marijuana Clinic.

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

SSN must be in XXX-XX-XXXX format.

Identification Documents

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Upload any record from your medical provider that shows you have been diagnosed for the condition you are seeking medical marijuana for. The proof can be a simple medical record showing your diagnosis or diagnostic code, a copy of a prescription, a photo of your medication bottle(s) showing the medication name, prescribing doctor and your name, or an MRI/x-ray, etc.
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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

Signature