Renewal Intake Form

    RENEWAL INTAKE FORM

    Name*:

    Middle Name:

    Last Name*:

    Date of Birth*:

    Email*:

    Cellphone Number*:

    Any Changes to Your Medications Since Last Visit? (If first visit with us, add your medications)*:


    Any new medical problems (if new to us, add your medical problems)*:


    Has marijuana been helping treat your medical condition? If so, how?*


    INFORMED CONSENT STATEMENT FORM

    I understand that medical marijuana may cause short term side effects including but not limited to psychoactive effects, dry and/or red eyes, dry mouth, short-term memory loss, decreased reaction time and attention, change in appetite, and change in mood. I should not drive or use dangerous or heavy machinery while under the influence of cannabis.

    Signature:*

    Date:*