Patient Intake | Still River Wellness

Name:*

First Name Last Name

Date of Birth:*

Gender:*

Male
Female

Address:

Town:*

State:*

Zip Code:*

MMJ Card #:*

Exp. Date:*

Drivers License #:*

Exp. Date:*

Home Phone:*

Cell:*

Email:*

Primary Care Physician:

MMJ Certifying Physician:

Registered Caregiver (if applicable):

Phone #:

A Registered Caregiver is a person chosen by the patient to act as their agent in obtaining their medication at the dispensary.If you feel that you need a caregiver, please contact your certifying physician.

Are you a veteran? (Please check one)*

Yes
No

*IF YES, PLEASE PROVIDE DOCUMENTATION*

Please Provide Documentation

Qualifying Condition:

Patients 18 years of age or older:*

Patients less than 18 years of age:*

Cerebral Palsy
Cystic Fibrosis
Irreversible Spinal Cord Injury with Objective Neurological Indication of Intractable Spasticity
Muscular Dystrophy
Osteogenesis Imperfecta
Severe Epilepsy
Terminal Illness Requiring End-of-Life Care
Uncontrolled Intractable Seizure Disorder
Not Under 18

Tobacco use?*

Yes
No

Alcohol use?*

Yes
No

Cannabis usage?*

Yes
No

Please describe, if Applicable

Have you had any negative cannabis usage effects?

Have you had positive cannabis usage effects?

Negative symptoms that I am currently experiencing: (Please check all that apply)*

Other

Health Conditions:

Allergies:

Current Medication:

Dosage:

Please list all current medications, including dosage

What outcomes do you hope to experience using medical cannabis?

What method of medical marijuana do you prefer? (Please check all that apply)*

Smoking
Vaporizing
Edibles
Oils
Tinctures
Concentrates
I am uncertain

Type of medicine preferred? (Please check what applies)*

High THC
Low THC
High CBD
Low CBD
1:1 Ratio THC / CBD
I am NOT sure of my medical needs

Preferred Medical Marijuana Products used currently, if any:

PATIENT INTAKE FORM

Step 1 of 3

MEDICAL CANNABIS ACKNOWLEDGMENT OF DISCLOSURE AND INFORMED CONSENT

MEDICAL CANNABIS PATIENT AGREEMENT