Patient Information

First Name *

Last Name *

Phone *

Email Address *

Birth Date *

Gender (Biological) *MaleFemale

Street Address *

Apartment, suite, etc

City *

State/Province *

ZIP / Postal Code *

Where did you hear about us?

Medical History

If other, please list *

For what condition do you seek medical marijuana? *

Marijuana History

Do you presently use marijuana to treat your medical condition? *YesNo

If yes, for what condition do you use marijuana? *

Does marijuana provide some relief for your symptoms? *YesNo

If yes, please describe *

How does marijuana compare with your usual prescribed medicines in relieving your symptoms? *I do not/have not taken prescribed medicine for my conditionPrescribed medicines work much betterPrescribed medicines work a little betterPrescribed medicines work the same as MarijuanaMarijuana works a little better than prescribed medicinesMarijuana works much better than prescribed medicinesMarijuana and prescribed medicines work best together

Have you had any negative/adverse reaction from use of marijuana?YesNo

If yes, please describe *

Frequency of marijuana use as medicine (i.e. daily, weekly, monthly etc.) *

Additional Information that you consider relevant to physicians evaluation

Caregiving

Do you currently need a caregiver to help you with your medical marijuana needs? *YesNo

Are you or someone you know interested in becoming a caregiver? *YesNoMaybe

Signature

I understand that typing my full name constitutes a legal signature confirming that I acknowledge and agree all above information is accurate and truthful.

Digital Signature *

Date *