New Patient

Patient Identification Information
Last First M.I.
(single, married, etc.)
Medical History
Medical History II
Effects of Cannabis & Other Drugs
ie: lockbox, etc.
Cannabis Use
Medical Conditions for which I use Cannabis
Please include a summary in your own words describing your complaints, symptoms or medical conditions you are being seen for. Include your experience with other types of treatments and/or therapies and why Cannabis is preferable to you.
I affirm that the above information is true and accurate to the best of my knowledge, and that any recommendation, certification, or approval associated with my use of Cannabis is contingent upon the accuracy of this information: