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 Name
Last Name
Patient Birth Date MM/DD/YYYY
*
Please select a month
January
February
March
April
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November
December
Month
Please select a day
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Day
Please select a year
2024
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Year
DATE OF BIRTH MM/DD/YYYY
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-
Month
-
Day
Year
Date
Phone Number
*
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Area Code
Phone Number
Address
*
Street Address
Street Address Line 2
City
State / 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 Disorder
Muscle cramps
Nausea
Anorexia
Pain
PTSD
Cron's Disease
Fibromyalgia
Insomnia - SLEEPLESSNESS
Headaches
Cancer
Seizures
Multiple Sclerosis
DEPRESSION
ARTHRITIS
GLAUCOMA
Other
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.
*
Browse Files
Cancel
of
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 so
The 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
*
Today's Date
*
-
Month
-
Day
Year
Date
How would you like to be notified next year that your renewal is coming due?
*
email
mail
none
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.
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.
SUBMIT
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