Below are the forms we will need for your first visit.

  • Patient Intake and Consent Form (Required)
  • Medical Records Release Form – Allows us to request your Medical Records

New Patient Intake and Consent Form

new-patient-intake

Follow up Visit Form

follow-up-intake

Recertification Intake and Consent Form

recert-intake

Medical Records Release Form

*Chronic Pain Referral Letter – If your practitioner is supportive of your decision to use medical marijuana, they may be willing to complete this form, which will streamline the process.

Medical Records Release _ Qualifying Conditons.pdf
Size : 92.887 Kb
Type : pdf

Medical Records Release _ ChronicPain.pdf
Size : 93.521 Kb
Type : pdf

Chronic Pain Referral Letter.pdf
Size : 71.477 Kb
Type : pdf

Distant Telemedicine Visits

  • We require medical records for your condition – Listed Above
  • All “Chronic Pain” telemedicine visits require a physical exam from past 12 months

New Patients
new-patient-intake
medical-records-release-_new-patient-phone

Recertification
recert-intake
medical-records-release-_recert-phone

Privacy Practices

Notice of Privacy Practices_Hipaa.pdf
Size : 87.954 Kb
Type : pdf