NEW YORK - MEDICAL FORM
NEW PATIENT
Name
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First Name
Last Name
State
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New York
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Date of Birth
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Month
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Day
Year
Date
Gender
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Male
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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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example@example.com
Are you taking any medications?
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What medication are you currently taking?
Have you ever experienced hallucinations before?
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Have you ever been diagnosed with schizophrenia?
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Do you have any history of bipolar disorder?
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What is your medical history like?
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Chronic Pain
Post - Traumatic Stress Disorder (PTSD)
ALS - Amyotrophic lateral Sclerosis
Cachexia
Multiple Sclerosis
Parkinson's Disease Epilepsy
Spinal Cord Injury with Spasticity
Neuropathy
Crohn's Disease
Alzheimer's Disease
Canser
HIV or AIDS Positive
Inflammatory Bowel Disease
Huntington's Disease
Hydrocephalus with intractable Headache
Wasting Syndrome
Muscular Dystrophy
Neuropathic Facial Pain
Osteogenesis Imperfecta
Opioid use or substance use disorder.
Other Condition
Any condition for which an opioid could be prescribed (provided that the precise underlying condition is expressly stated on the patient’s certification).
Substance Use Disorder
How long have you been dealing with this pain, in month/year?
What condition are you dealing with ie chronic pain seizures?
Driver's License/State ID Card
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Medical Marijuana Card Evaluation
The $199 fee includes your consultation fee, physician copay, and the medical evaluation for your recommendation. PAYMENT IS FULLY approved REFUNDABLE IF YOU ARE NOT GET APPROVED
$
199.00
Renewal
The $169 fee includes your consultation fee, physician copay, and the medical evaluation renewal for your recommendation. PAYMENT IS FULLY REFUNDABLE IF YOU ARE NOT GET APPROVED
$
169.00
Consultation
The $69 fee includes your consultation fee, physician copay.
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69.00
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