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 *

Cell Phone Number

Cell Phone Carrier

Email Address *

Are you a new or transfer patient? *

Yes

No

Do you have a caregiver? *

Yes

No

Caregiver's Name

Caregiver's Phone Number

Qualifying Condition for Medical Marijuana: *

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

Did you provide us with your Medication List

Yes

No

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 Fatigue Stomach Cramping Muscle Spasms Nerve Pain Reduce Opiates Other

Additional information you would like the pharmacist to be aware of prior to therapy recommendation:

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