Green Clinics St. Louis

Questionnaire
PATIENT INFORMATION
Select Physician
First Name
Middle Name
Last Name
Gender
Address
Address 2
City
State
Zipcode
County
Height
Weight
Drivers Lic. / ID #
Phone
Email
Contact Me By
How Did You Hear About Us?
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)
UPLOAD MEDICAL RECORDS
Please upload medical records now. If you do not have them available you must bring them to your appointment or we will have to reschedule your appointment.
Upload
Risks/Side Effects
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”