Patient Form
First Name
Middle Name
Last Name
Gender
Drivers Lic. or State ID
Email
Phone
Contact Me By
Date Of Birth
How Did You Hear About Us?
MEDICAL INFORMATION
CALIFORNIA medical cannabis qualifying conditions shown below:
Check each medical problem that you suffer from or check other to have the doctor evaluate your unique condition. At least one box must be checked to qualify.
Current Medications (Leave Blank If None)
Do You Have Any Drug Allergies?
UPLOAD DRIVERS LIC. OR STATE ID What is this?
Upload
Uploading
UPLOAD MEDICAL RECORDS What is this?
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.
Upload
DISCLAIMERS
RELEASE OF LIABILITY
ATTESTATION
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”