• Health Information & Patient Agreement

    This is a 3-part form. Providing your background information and consent for medical records release will greatly expedite the registration process.

  • Mobile is preferred

  • If you have a Primary Care Physician, please provide their name and contact information.

  • Why are you are seeking a recommendation to use medical marijuana and/or see our physician for pain management?

  • Include the approximate dates of each stay

  • Name and Location

  • Please include vitamins, herbal or natural supplements and prescription medications which you are currently taking. Please note the dosage if possible.

  • 1/3