top of page

Patient Forms

You've booked your appointment, now what?

Step 1. 

Take a photo of the FRONT of your driver's license or State Issued ID. If you require a Caregiver you will also need picture of the FRONT of their ID. 

Step 2.

Fill out the Form Below COMPLETELY. The phone number you provide is the number our Team  will call for your telehealth appointment. Add the photos of IDs where required.

Step 3.

Be at the phone number on file for teledoc appointments or at the location for your in-person appointment 10 minutes early.

Patient Intake Form

Patient Information

Date of Birth
Month
Day
Year
Over 18 Confirmation
Yes
No
Do You Need A Caregiver?
Yes
No

Medical Information

Qualifying Condition
How long have your experience these symptoms?
Less than 6 months
6-12 months
1-5 years
More than 5 years
Date of Original Diagnosis
Month
Day
Year
What is your current experience level with cannabis?
Never used / Beginner
Occasional user (a few times a month)
Regular user (daily or weekly)
Drawing mode selected. Drawing requires a mouse or touchpad. For keyboard accessibility, select Type or Upload.
bottom of page