Patient Intake Form

Full Legal Name

Cell Phone
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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

Specify Gender

Your Date of Birth (DOB)

Weight (lbs)

Height (feet)

Height (inches)

Social Security Number

SSN must be in XXX-XX-XXXX format.

Patient Registry Number (optional)

Drivers License #

Drivers License Issued State

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

Medical Record Diagnosis (.jpg, .png, .gif, .jpeg, .pdf) 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.

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.

Caregiver's Name

Caregiver's Phone #

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

How did you hear about us? *

If you answered 'Friend or Family', please provide their first and last name. If you answered 'Other', please provide who or how you were referred you.

Do you have a Groupon Voucher? If so, please provide the 8-10 digit voucher code here. (Code can be found beneath the barcode on the voucher.)

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.