Initial Paperwork

Before coming to your first appointment please download, fill out, and bring the following forms:

Privacy Policy Acknowledgement Form

Medical History Form

Medical Cannabis Acknowledgement of Disclosure and Informed Consent

Patient Intake Form

Patient Intake Form

Patient Name *

Date of Birth *

Address *

City *

Zip *

MMP Card Number *

MMP Card Expiration *

CT Drivers License Number

CT Drivers License Expiration

Cell Phone Number

Cell Phone Carrier

Email Address *

For which diagnosis were you approved for use of medical marijuana? (select one) * Post Traumatic Stress Disorder Cancer Parkinson's Disease Cachexia Glaucoma Multiples Sclerosis Wasting Syndrome HIV/AIDS Epilepsy Crohn's Disease Damage to nervous tissue of the spinal cord with objective neurological indication of intractable spasticity Sickle Cell Ulcerative Colitis Complex Regional Pain Syndrome ALS Severe Psoriasis and Psoriatic Arthritis Post Laminectomy Syndrome with Chronic Radiculopathy

Authorizing Physician *

Authorizing Physician Contact Information *

Do you have experience with cannabis? * Experienced Moderate Beginner None

Preferred form of use? Smoking Vaporizing Edibles Oils Concentrates (wax/shatter/crumble) Capsules Topicals Sublingual Film Strips

Primary Symptom Relief Goals Difficulty staying asleep Difficulty falling asleep General insomnia Nightmares Seizures Tremors Muscle Pain General pain Ocular pressure Migraines Depression Anxiety Poor appetite Nausea Hyperactive Bowels Abdominal Cramping Option 17

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