Patient Questionnaire
First Name
Last Name
Drivers Lic. or State ID
Date Of Birth
Apartment #
Zip Code
Contact Me By
May I leave a voicemail?
Referred By
Are you a Florida Resident?
Current Medications (Leave Blank If None)
Do You Have Any Drug Allergies?
Social Security #
Current Weight
Qualifying Conditions
Please select the condition(s) in which you seek Medical Marijuana for. If other please specify, field must not be blank.
Health History
List any medical conditions below
Health History and Review of Symptoms
Review the following symptoms, check the symptoms that are current and that you have been treated for,
You may select multiple options.
Are you currently receiving treatment for the condition(s) that you are being evaluated for medical marijuana? *
History of mental illness or major health problems in your immediate family: parents, grandparents, or siblings? *
Have you used cannabis in the past to treat your medical condition? *
Do you have a history of substance abuse or addictions? *
Do you smoke tobacco? *
Preferred method of marijuana use as a medicine: *
You may select multiple options.
You do understand that smoking is harmful to your lungs and is not medically advised? *
Have you had any negative/adverse reactions from cannabis use? *
Additional Information that you consider relevant to the physician’s evaluation:
How likely are you to recommend us to someone you know?
Are there medical records that document your medical condition(s)?
Records Release Request
* Note: This can also be done at the office and is not required to complete form
Upload your prescription bottle by clicking below.
HIPAA Patient Consent Form
Malpractice Insurance Notice
Informed Consent for Treatment with Medical Cannabis
Practice Consents
Disability Notice
Digital Signature
By electronically signing this form, I declare under penalty of perjury that the information on this form is true and correct to the best of my knowledge and understand that the typed electronic signature shall have the same legal effect as an original signature.
Use Your mouse or finger to sign below. Click "Add Signature" after signing.