CONFIRM YOUR APPOINTMENT

You must fill out the form below to get your records processed and appointment approved. You’ll receive an email confirmation once your records have been verified.

"*" indicates required fields

Name*

First Name Last Name

Phone number*

Email*

Date of birth*

MM slash DD slash YYYY

Driver's license #

Address*

Street Address Street Address Line 2 City State / Province Postal / Zip Code

Are you presently under the care of another medical physician and/or clinic?*

Yes

Name of Physician/Clinic (Please include phone number and address if known):

Are you transferring an existing medical marijuana certification?*

Yes

Name of Physician/Clinic (Please include phone number and address if known):

What is/are your medically diagnosed condition(s)?

Reason(s) for your visit today?

Any major medical concerns?

Any alternative therapies/methods you are using for treatment?

If you are taking medications(s) please list them below:

If you have allergies please list them below:

If you have been hospitalized, and/or had any major surgeries please list them below:

Please check all the reasons for your visit

Cancer

Epilepsy

Glaucoma

HIV / Aids

Crohn's

Parkinson's

PTSD

ALS

Multiple Conditions

Chronic Pain

Terminal Condition

Other

Reasons for your visit (Other)

List any lung/breathing concerns (and how often/long they occur):

List any cardio/heart problems (and how ofter/long they occur):

Do you smoke cigarettes?*

Yes

How many cigarettes a day and for how long (years)

Do you drink alcohol?*

Yes

How many drinks a day and for how long (years)

Do you have a history of Drug Abuse?

Yes

Are you unable to work because of a medical injury?*

Yes

What is the injury?

Are you currently employed?*

Yes

What is your occupation?

Are you on Parole?*

Yes

More info about your Parole - Including the year

Have you been convicted or in the proceedings for a DUI?*

Yes

More info about your DUI case- Including the year

Are you currently pregnant?

Yes

Are you breast feeding?

Yes

Are you using birth control?

Yes

Signature*

I hereby certify that the above information regarding my medical history and condition is true and correct to the best of my knowledge

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