Green Link Rx Intake Form

Patient Green Link Rx Intake Form

Please take a few moments to complete this medical history review
All certification and renewal appointments are currently being done by video conference from the safety and comfort of your home. PLEASE NOTE: INFORMATION PROVIDED MUST MATCH INFORMATION ON THE STATE REGISTRATION WEBSITE.
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email - MUST BE THE SAME EMAIL USED TO REGISTER WITH THE STATE *
example@example.com
Phone Number*
Please enter a valid phone number.
Gender*
Birth Date*

MonthDayYear
Phone Number*
Please enter a valid phone number.
Qualifying Medical Conditions (Please Check All That Apply)*

Amyotrophic Lateral SclerosisAnxiety DisordersAutismCancer (Including Remission Therapy)Crohn's DiseaseDamage to the nervous tissue of the central nervous system (brain-spinal cord) with objective neurological indication of intractable spasticity and other associated neuropathiesDyskinetic and Spastic Movement DisordersEpilepsyGlaucomaHIV / AIDSHuntington's DiseaseInflammatory Bowel DiseaseIntractable SeizuresMultiple SclerosisNeurodegenerative DiseasesNeuropathiesOpioid Use DisorderParkinson's DiseasePost-Traumatic Stress Disorder (PTSD)Severe chronic or intractable pain of neuropathic origin or severe chronic or intractable painSickle Cell AnemiaTerminal IllnessTourette's Syndrome
Have you registered an account with the state?*

NoYes
Have you registered paid the $50 fee with the state on the payment tab on their website?*

NoYes
If registered with the state, what is your ID number?
Is this a recertification?*

NoYes
Do you need a medical marijuana caregiver to assist with getting medication or due to limited mobility etc?*

YesNo
Are you a medical marijuana caregiver applying to assist with getting medication for someone else or helping them due to their limited mobility etc? If this is the case, then please note that you will need to: ADDITIONALLY obtain fingerprints and the state will perform a background check per the state's requirements on their website in order to be approved. This process may take 30-60 days.*

YesNo
Please attach a JPEG photo of your PA drivers license. (Must not be expired & name must match name on application)*

Cancelof
Please attach any supporting documentation of your medical marijuana necessities. ie: pain management records, pertinent medical records etc. (You can provide these at prior to virtual appointment by emailing them to info@mydrlori.com

Cancelof
Photo front & back of credit card for payment $250 (1 year)

Cancelof
Should be Empty:

Patient Green Link Rx Intake Form

All certification and renewal appointments are currently being done by video conference from the safety and comfort of your home. PLEASE NOTE: INFORMATION PROVIDED MUST MATCH INFORMATION ON THE STATE REGISTRATION WEBSITE.