For internal promotional use only Preview on Page 1

For internal promotional use only 2026

The document is an Initial Patient Intake Form for medical marijuana, collecting personal information, medical history, and preferences regarding cannabis use. It includes sections for patient demographics, state-approved diagnoses, current medications, and acknowledgment of risks associated with cannabis use. Additionally, it outlines privacy practices and requires patient signatures to confirm understanding of the risks and compliance with the medical marijuana program.

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Click ‘Get Form’ to open it in the editor.
Begin by entering your personal information, including your first and last name, date of birth, and gender. Ensure accuracy as this data is crucial for your medical records.
Fill in your address details, including town, state, and zip code. This helps in establishing your residency for medical marijuana eligibility.
Select your preferred method of contact and provide relevant phone numbers and email. Indicate the best times to reach you for convenience.
Complete the sections regarding your primary care physician and any registered caregivers if applicable. This information is vital for coordinating care.
Indicate whether you are a veteran and how you heard about the service. This can help tailor support to your needs.
Check all applicable diagnoses and symptoms you are experiencing. This section is essential for understanding your health condition.
Review all entries for accuracy before submitting the form to ensure a smooth process.

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