1. HC Appointment Request Form

Patient's Preferred Name (First and Last)

Please write the name you'd like the doctor to use. If you are filling this out as a caregiver for a patient, please write the patient's name and not your own.

Phone

Your preferred phone numberFormat: (000) 000-0000.

Contact E-mail

Confirmation EmailPlease confirm your email above

Are you a new or renewing MMJ patient? Select one.

All new patients must register with the Department of Health and obtain a Patient ID# before their consultation. You can do that through this link.

If you have a PA Department of Health Patient ID#, please enter it below.

If you are a New MMJ Patient, this DoH-issued number is required to successfully schedule your appointment.

Has your card expired?

When does your card expire?

Date

Do you qualify for any of the available discounts? Please select only one.

Do you have any communication preferences? Check all that apply.

I consent to receiving email and SMS correspondence from Herbal Care Rx for scheduling purposes.

You will have two options; you can schedule your appointment now using this form, or you can wait to be contacted by us using your preferred mode of contact.

- Input your Department of Health ID number above

- Complete the Doctor's patient intake form

- Select your preferred appointment date and time

- Pay the doctor in advance for the consultation

To book your appointment now, you will need to do the following

Please click Submit below when you are ready to proceed.