Patient Form
PATIENT INFORMATION
First Name
Middle Name
Last Name
Gender
Address
Address 2
City
State
Zipcode
County
Height
Weight
Social Security #
Phone
Email
MEDICAL INFORMATION
SYMPTOMS
FLORIDA 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.
PATIENT MEDICAL HISTORY
Immediate family medical issues
(Indicate if you or your immediate family had any of the following problems)
CODE OF CONDUCT

At 3C, your are provided with a professional, compassionate, and private evaluation in the privacy of your own home/office, nursing home/ALF or our office to legally obtain a Florida Medical Marijuana Card. Medical Cannabis is not only a medical issue, but a legal one as well. All medical board guidelines and Florida law are followed so that your approval is legal, ethical and defensible in court. Mission: To provide compassionate alternative medical care, improving the quality of each patient’s life, through medical therapy, education, and training. Vision: To provide a concierge style alternative medical therapy brought to you either in office or in the privacy of your own home with the highest level of care, patient education, and patient advocacy allowed within the letter of the law. Values: Compassion Patient Advocacy Patient Education Life Balance Quality of Life We value respect: abusive, aggressive language or behaviors will not be tolerated and may led to the revocation of the doctor/patient relationship and cancellation of recommendations and orders.

APPOINTMENT FEES

This is a non-refundable payment and will count towards my declared sliding scale fee. If I do not keep my scheduled appointment, the fee is not refundable. If I need to re-schedule, I can do so no less than 24 hours in advance, and the fee will be applied toward my new appointment. A maximum of one reschedule is allowed. 3C  helps those who are less fortunate, we have developed a sliding scale fee structure based on total household income. Your fee will correlate to what you declare is your total gross household income. I attest that my stated gross household income that I declare is correct for my certification or re-certification fee and that I qualify for the offered discount for said services. *Recertifications required each 210 days

HIPPA/PRIVACY

Concierge Compassionate Care/Green Palms uses HIPPA compliant practices and systems. I hereby acknowledge that I will be provided a copy of the notice of how my information is used only if I request a copy at the time of my appointment.

LIABILITY WAIVER

LIABLITY WAIVER AND RELEASE In consideration of my evaluation to be performed by or on behalf of Concierge Compassionate Care, LLC/Green Palms, I, my heirs, assigns and anyone acting on my behalf, agree to hold Concierge Compassionate Care, LLC, and Green Palms, LLC staff, physicians, and their principal agents, officers, directors, and employees free and harmless from any and all claims, damages and causes of action relating to or arising out of: (1) my use or possession of cannabis (marijuana), or (2) the denial of my application for a medical marijuana card for any reason. I understand and acknowledge that: 1. Concierge Compassionate Care, LLC/Green Palms is not a medical marijuana dispensary and cannot provide me with medical marijuana. 2. A physician’s certification that I may benefit from the use of medical marijuana does not guarantee that the use of medical marijuana will be effective at alleviating or helping any signs, symptoms, or disease states that I may suffer from. 3. I am responsible to know the Florida State laws regarding the acquisition, use, and restrictions concerning the use of medical marijuana. Some of this information may be found at the Floridahealth.gov website. 4. I certify that I fully understand the potential risks and side effects related to the use of medical marijuana. 5. I fully accept the responsibility and assume all risks associated with the use of medical marijuana. 6. Neither Concierge Compassionate Care, LLC/Green Palms nor anyone acting on its behalf has made any representation to me about the application or enforcement of State or Federal Law in connection with the possession or use of medical marijuana. 7. Neither Concierge Compassionate Care, LLC, its physicians, associates nor staff is addressing specific aspects of my medical care, is in no way establishing themselves as my primary care, and are not responsible for any of my medical care outside of my medical marijuana certification and recommendation. 8. Neither Concierge Compassionate Care/Green Palms, its physicians, nor staff advises or condones that I discontinue any treatment or medications that I am currently taking or under-taking and I agree to follow up with my prescribing or treating physician about treatments and medications. 9. I represent that Concierge Compassionate Care, LLC/Green Palms, its physicians and staff have (a) explained to me the nature and purpose of medical marijuana (cannabis) therapy, including its benefits, side effects and risks, (b) answered any and all questions that have I concerning the use of medical marijuana to the best of their ability. I also attest under penaty of law that: I will not do any audio or video recordings without consent: I am not a journalist or a reporter; I am not a federal, state or local government employee investigating Concietge Compassionate Cate, LLC or Gren Palms, LLC.

PATIENT 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”