Beach Health Center Patient Forms

Beach Health Center Patient Intake Form

Your personal data privacy is protected through our system compliant with HIPAA. FILL OUT THIS FORM IF YOU ARE COMING IN PERSON TO GET YOUR MED CARD AT ONE OF OUR WALK IN LOCATIONS. IF YOU ARE LOOKING FOR OUR VIRTUAL APPLICATION FOR AN IMMEDIATE DIGITAL MED CARD THIS IS THE LINK https://hipaa.jotform.com/221665887581167
Patient Name*

First NameLast Name
Patient Birth Date MM/DD/YYYY*

MonthDayYear
DATE OF BIRTH MM/DD/YYYY*

MonthDayYear
Date
Phone Number*

Area CodePhone Number
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Patient E-Mail*
Patient Medical History
Do you have any of the following conditions/symptoms? (Please check all that apply)*

Anxiety DisorderMuscle crampsNauseaAnorexiaPainPTSDCron's DiseaseFibromyalgiaInsomnia - SLEEPLESSNESSHeadachesCancerSeizuresMultiple SclerosisDEPRESSIONARTHRITISGLAUCOMAOther
Please attach your valid Maine State ID / Driver's License (temporary paperwork is not acceptable must be a valid card) IF YOU DO NOT HAVE A VALID MAINE STATE DRIVERS LICENSE OR ID WE CANNOT CERTIFY YOU.*

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Patient Agreement & Consent

* Please sign below that you have read, understood, and answered the above questions truthfully to the best of your knowledge. Please be advised that payment for all services will be due at the time services are rendered unless prior arrangements have been made.
Please read and check each item:*

I hereby declare that I have truthfully and completely disclosed all information regarding my medical and behavioral health conditions.I understand that Beach Health Center will not send my medical information or card status to anyone unless I send a written request to do soThe Maine Medical Marijuana Program is protected by the medical privacy act. I understand that no one knows I have a MMMP card unless I tell them or show them my card. I understand that there is no registry in Maine.
Patient Signature*

Clear
Today's Date*

MonthDayYear
Date
How would you like to be notified next year that your renewal is coming due?*

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WHEN AND WHERE DO YOU PLAN TO COME IN AND BE SEEN? OR TEXT US AT 207-229-4492 TO GET OUR CURRENT SCHEDULE
This form is for anyone coming in person to get their Maine Cannabis Certificate. Please text us at 207-229-4492 when you are planning to come and we will have your card ready if you submit 2 hours prior to arrival and attach your Maine ID to this form. SEE OUR LOCATIONS PAGE FOR POP-UPS. WE DO NOT HAVE AN OOB OFFICE.

IF YOU ARE LOOKING TO RENEW YOUR MED CARD AND ARE ALREADY A PATIENT WITH BEACH HEALTH CENTER EMAIL OR TEXT US AT 207-229-4492 OR beachhealthcenter@yahoo.com WITH YOUR NAME, MAILING ADDRESS AND NOTE REQUESTING TO RENEW.
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Beach Health Center Patient Intake Form

Patient Medical History

Patient Agreement & Consent