Patient Form
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First Name
Middle Name
Last Name
Gender
Address
Address 2
City
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Email
Phone
Drivers Lic. or State ID
Date Of Birth
How Did You Hear About Us?
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UPLOAD MEDICAL RECORDS
Sharing your prior medical records is not required and completely optional for prospective patients. Your information is private and will remain in a HIPAA-compliant secure system. Any information you provide will NOT be accessible by your health insurance company, employer, or any other entity.
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DISCLAIMERS
ATTESTATION
RELEASE OF LIABILITY
CONSENT TO PARTICIPATE IN TELEMEDICINE CONSULTATION
DISQUALIFIERS
DIGITAL SIGNATURE
By electronically signing this document, you declare under penalty of perjury that the information on this form is true and correct.
Additionally, you are also aware that your recommendation may be revoked at any time if you have perjured or misrepresented yourself on this form.
Note: Filling out this questionnaire does not guarantee a medical marijuana recommendation.
Please sign below using a stylus, your mouse, or your finger and then click “SUBMIT”