Initial Paperwork Patients FAQ CT Medical Marijuana Laws & Regulations Recipes Patient Orientation Video BEFORE COMING TO YOUR FIRST APPOINTMENT PLEASE DOWNLOAD, FILL OUT, AND BRING THE FOLLOWING FORMS Privacy Policy Acknowledgement Form (Opens in New Window) Medical History Form(Opens in New Window) Medical Cannabis Acknowledgement of Disclosure and Informed Consent(Opens in New Window) PATIENT INTAKE FORM * Denotes Required Field Patient Name* First Last Please enter your first and last nameDate of Birth* Month Day Year Please enter your date of birth.Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Please enter your addressMMP Card Number* Please enter your MMP Card NumberMMP Card Expiration* Please enter your MMP Card ExpirationCell Phone NumberPlease enter your cell phone numberEmail Address* Please enter your email addressAre you a transfer patient?* Yes, I am a transfer patient No, I am not a transfer patient Do you have a caregiver?* Yes, I have a caregiver No, I do not have a caregiver Caregiver's Full Name First Please enter Caregiver's Full NameQualifying Condition for Medical Marijuana* Please enter your qualifying condition for medical marijuanaAuthorizing Physician* Please enter your authorizing physicianAuthorizing Physician Contact Information* Please enter your authorizing physician's contact informationDo you have experience with cannabis?*ExperiencedModerateBeginnerNonePlease choose your experience with cannabis from the dropdownPreferred form of use?SmokingVaporizingEdiblesOilsConcentratesCapsulesTopicalsSublingual Film StripsPlease choose your preferred form of use from the dropdownDid you provide us with your Medication List?* Yes, I have provided my medication list No, I have not provided my medication list Primary Symptom Relief GoalsDifficulty Staying AsleepDifficulty Falling AsleepGeneral InsomniaNightmaresSeizuresTremorsMuscle PainGeneral PainOcular PressureMigrainesDepressionAnxietyPoor AppetiteNauseaHyperactive BowelsAbdominal CrampingFatigueStomach CrampingMuscle SpasmsNerve PainReduce OpiatesOtherPlease select your primary symptom relief goals from the dropdownAdditional information you would like the pharmacist to be aware of prior to therapy recommendationPlease let us know of any additional information you would like the pharmacist to be aware of prior to therapy recommendation.EmailThis field is for validation purposes and should be left unchanged. Δ
