NEW YORK - MEDICAL FORM
RENEWAL
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New York
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Date of Birth
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Gender
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Address
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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 experienced hallucinations before?
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Have you ever been diagnosed with schizophrenia?
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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
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Provide some basic medical history and book an appointment with a licensed marijuana doctor. The $169 fee includes your consultation fee, physician copay, and the medical evaluation for your recommendation.
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