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NEW PATIENT FORMS
First Name
Last Name
Email
Birthday
Phone
ADDRESS
FLORIDA ID NUMBER
SOCIAL SECURITY NUMBER
WHAT IS YOUR GENDER
MALE
FEMALE
HAVE YOU HAD MEDICAL MARIJUANA CARD IN PAST
YES
NO
DO YOU HAVE A QUALIFYING MEDICAL CONDITION THAT HAS BEEN DIAGNOSED BY A DOCTOR?
YES
NO
WHAT QUALIFYING MEDICAL CONDITION DO YOU HAVE?
CANCER
PTSD
CROHN'S DISEASE
GLAUCOMA
EPILEPSY
HIV OR AIDS
MS/ MULTIPLE SCLEROSIS
PARKINSONS
ALS / Amyotropic Lateral Sclerosis / Lou Gehrig's Disease
OTHER CONDITION OF "SIMILAR KIND OR CLASS" TO THE ONE ABOVE (DESCRIBE BELOW).
WHAT OTHER QUALIFYING MEDICAL CONDITION DO YOU HAVE?
HOW DOES YOUR CONDITION EFFECT YOUR EVERY DAY LIFE?
HOW WOULD YOU BENEFIT FROM MEDICAL MARIJUANA?
WHAT PRE-EXISTING CONDITIONS DO YOU HAVE? INCLUDE ALL DIAGNOSIS.
WHO IS YOUR PRIMARY CARE DOCTOR? WHO IS THE DOCTOR WHO DIAGNOSED YOU WITH YOUR MEDICAL CONDITION(S)?
HAVE YOU EVER BEEN ADJUDICATED INCOMPETENT?
YES
NO
DO YOU HAVE OR HAVE YOU EVER HAD SUICIDAL THOUGHTS? OR HEARING VOICES?
YES
NO
DO YOU UNDERSTAND THE MEDICAL RISKS ASSOCIATED WITH MEDICAL MERIJUANA USE?
YES
NO
HAVE YOU EVER BEEN ADDICTED TO DRUGS, ALCOHOL, OR ILLEGAL SUBSTANCES?
YES
NO
DO YOU USE ILLEGAL DRUGS OR SUSBSTANCES?
YES
NO
ARE YOU A FLORIDA RESIDENT?
YES
NO
DO YOU BELIEVE MARIJUANA USE WOULD OUTWEIGHT THE RISK FOR YOU AND YOUR MEDICAL CONDITION?
*
Required
YES
NO
DO YOU UNDERSTAND THE LEGAL AND MEDICAL CONSEQUENCES OF USING MARIJUANA?
*
Required
YES
NO
BY CLICKING BELOW YOU AGREE THAT YOU ARE PROVIDING ACCURATE AND TRUE STATEMENTS ABOVE, AND YOU ARE THE PERSON OR LEGAL GUARDIAN OF THE PERSON WHO IS DESCRIBED ABOVE. YOU ALSO UNDERSTAND THAT THE DOCTOR WILL MAKE A DETERMINATION IF YOU QUALIFY FOR A MEDICAL MARIJUANA CARD AND THAT IF YOU DO, YOU MUST PAY $75 REGISTRATION FEE TO FLORIDA STATE AND RENEW YOUR CARD EVERY YEAR TO KEEP IT ACTIVE, AND REGULARLY VISIT THE DOCTOR FOR DOSAGE ADJUSTMENTS AND HEALTH CHECK-UPS. YOU ALSO STATE YOU ARE A FLORIDA RESIDENT WITH A LEGAL FLORIDA ID OR AS ALLOWED BY FLORIDA LAW.
*
Required
YES
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