Patient Intake

First Name

Date Of Birth


Which location works best for you?
Referral Source:
Best Time/Day for Appointment?

Past Medical History

Conditions/Complaints: * Please include when you first noticed the symptoms and when you received the diagnosis

Please describe the medical condition or complaint that you are seeking a recommendation for medical marijuana

I have seen my doctor for this condition:

Do you have your medical records?:
Preferred Method of Contact