VIRGINIA - MEDICAL FORM
NEW PATIENT
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First Name
Last Name
State
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Virginia
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Gender
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Male
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Date of birth
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Month
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Day
Year
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Address
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Street Address
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Phone Number
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Email
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Are you taking any medications?
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What medication are you currently taking?
Have you ever been diagnosed with schizophrenia?
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Have you ever experienced hallucinations before?
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What is your medical history like?
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Alzheimer’s Disease
Amyotrophic Lateral Sclerosis (ALS)
Anxiety
Autism
Cachexia and wasting syndrome
Cancer
Crohn’s Disease
Chronic Pain
Epilepsy and other seizure disorders
Fibromyalgia
Glaucoma
Hepatitis C
Huntington’s Disease
Inflammatory Bowel Disease (IBD)
Multiple Sclerosis (MS)
Parkinson’s Disease
Post-Traumatic Stress Disorder (PTSD)
Sickle Cell Anemia
Tourette’s Syndrome
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New Patient
The $199 fee includes your consultation fee, physician copay, and the medical evaluation for your MMJ Card
$
199
Renewal
The $169 fee includes your consultation fee, physician copay, and the medical evaluation renewal for your MMJ Card
$
169
Consultation
The $69 fee includes your consultation fee, physician copay, and the medical evaluation for your MMJ Card
$
69
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