Questionnaire
PATIENT INFORMATION
Patient Type
Select Physician
First Name
Middle Name
Last Name
Gender
Address
Address 2
City
State
Zipcode
County
Height
Weight
Social Security #
Drivers Lic. / ID #
Phone
Email
How Did You Hear About Us?
Contact Me By
MEDICAL INFORMATION
SYMPTOMS
MISSOURI 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)
Social Questions
Additional Information


UPLOAD DRIVERS LIC. OR STATE ID What is this?
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UPLOAD PATIENT PHOTO What is this?
Take a Selfie or Upload Your Photo
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UPLOAD MEDICAL RECORDS
Have your medical records already? Feel free to upload them here. Photos of your prescription medications might work too! We will need them before your appointment. If you need help obtaining your records, please email Intake@KindRemedyKC.com and we will gladly request your records from your primary care physician.
Upload
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”