Tumbleweeds Health Center-Telehealth Intake and Consent Form

Patient Information - TeleHealth Intake
Patient Name*

First NameMiddle NameLast NameSuffix
Date of Birth*

MonthDayYear
Date
Gender*

MaleFemale
Type of Identification*
Please upload Drivers License or ID*

Upload Arizona STATE ID
*AZ State Driver's license, AZ State Identification, or US passport ONLY Cancelof
Residential Address*

Street Address

Street Address Line 2

CityState

Zip Code
Mailing Address*

Mailing Address

Mailing Address Line 2

CityState

Zip Code
Phone Number*

Area CodePhone Number
Email*
example@example.com
Are you requesting to cultivate? (must live 25 miles away from a dispensary)*
Would you like to be notified of Clinical Studies through AZDHS?*
Do you receive Food Stamps? (MUST submit proof)*
Please upload your Proof of Food Stamps

Upload proof of food stamps
Your award letter, SNAP card, or online verification Cancelof
Are you a Veteran?
*I authorize Tumbleweeds Health Center to access my AZDHS portal for the sole purpose of processing my application. *

Clear
Sign here
*AZDHS Portal Password
Portal Password
Qualifying Condition
Which Qualifying condition would you like to be certified for?*
Are you taking any medications?*
If any, Please list:*
Please upload ANY Medical Records you may have that apply to your Qualifying Condition.

Upload Medical Records HEre
Most recent medical records Cancelof
Please upload a picture of YOU for your Medical Card*

UPLOAD PHOTO HERE
No sunglasses, headbands, or hats Cancelof
Are you pregnant?*
Breastfeeding?*
How did you hear about us?*

RecertificationTucson WeeklyFacebookGoogle SearchYelpTV CommercialDispensaryOther
Doctor/Office Name:
1. Service

The healthcare facility will need to collect and record the patient's personal and medical information. During the telehealth visit, the patient will be contacted via videoconference software.

2. Software

Telehealth visits are held by using different software in order to increase the productivity and effectiveness of the visits. All information is password-protected.

3. Confidentiality

All the medical or personal information of the patient will be kept private. The medical condition of the patient will not be used for further researches.

4. Rights

The patient can withdraw or withhold the consent at any time and it will not affect the further treatment.

The patient can end the videoconference with the healthcare consultant, physician, or professional at any time.
Signature and Submission
I have been informed about the telehealth practices and I have been given the opportunity to ask questions about services, consultation, and practice. I have acknowledged that the information I have given in the form is accurate and complete. I have understood and given my consent to participate in telehealth services.
Patient Name*

First NameLast Name
Date*

MonthDayYear
Date
Signature

Clear
Should be Empty:

Patient Information - TeleHealth Intake

Qualifying Condition

Signature and Submission