2. Herbal Care Combined Patient Intake Form

Herbal Care Rx Intake Form
Full Name*
E-mail*
if you do not have your own email, then please use the email of someone close to you.
Contact Number:*
If you do not have your own phone number, please use a number of someone close to you that you can be reached at.
I am a...*

New MMJ PatientRenewing MMJ Patient
Date of birth*

MonthDayYear
Home Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
PCP information: this is not required.
Your Primary Care Provider's Information. Leave blank if you do not know your PCP or do not have a PCP
Primary Care Provider's name

First NameLast Name
Contact Number
Please enter a valid phone number.
Emergency contact number
Emergency Contact's Phone number
Please enter a valid phone number.

Release of Liability
I attest that the information on this form is correct and any medical history presented or discussed with the doctor is factual and complete to the best of my knowledge. I do not plan or intend to use my physician’s recommendation for the purpose of illegally obtaining medical cannabis.

I understand that I must be a PENNSYLVANIA resident to obtain a certification/recommendation for the use of medical cannabis.

I understand that the cannabis plant is not regulated by the United States Food and Drug Administration and therefore may contain unknown quantities of active ingredients, impurities and/or contaminants. I acknowledge that the state of PA, however, does have a regulatory body in place that monitors the quality and content of medical cannabis that is sold in this state. I understand the potential risks associated with a daily consumption of medical cannabis, including risks with respect to the effect on my cardiovascular and pulmonary systems and psychomotor performance, as well as potential drug dependency. I am aware that the benefits and risks associated with the use of cannabis are not fully understood and that the use of cannabis may involve risks that have not yet been identified. In requesting an certification/recommendation for the use of medical cannabis, I assume full responsibility for any and all risks involved in this action.

I have been advised that medical cannabis smoke contains chemicals that may be harmful to my health. Recent research suggests that vaporizing cannabis may eliminate exposure to particulate matter which can be harmful to the lungs. Should respiratory problems or other ill effects be experienced in association with its use, it should be discontinued and reported to the physician immediately.

I understand that the use of medical cannabis may affect my coordination and cognition in ways that could impair my ability to drive, operate machinery, or engage in potentially hazardous activities. I assume full responsibility for any harm resulting to me and/or other individuals as a result of my use of cannabis.

Pennsylvania’s Medical Cannabis Act 16, approved April 12, 2016 provides for the possession of medical cannabis for personal medical use. I acknowledge that the physician, staff and representatives of this practice are not providing medical cannabis, nor are they encouraging any illegal activity in obtaining medical cannabis.

I, the undersigned, hereby request a consultation by the physician for purposes of determining the appropriateness of medicinal cannabis treatment. The physicians at Herbal Care Rx will assess my appropriateness for use of medical cannabis only and are in no way establishing themselves as a primary care provider. Should an approval be made for my medicinal use of cannabis, I understand that there is a renewal date specified by the physician depending on my condition. I understand that it is now my responsibility to discuss with a physician the possible continuance of cannabis use beyond the term of the approval.

I acknowledge that my consultation with Herbal Care Rx is solely for the purposes of assessing my fitness for use and not for providing specific information about the use of cannabis for the treatment of symptoms and conditions. In accordance with state law, if I require information and guidance about cannabis use for the treatment of specific symptoms and conditions, I may consult the pharmacist or nurse practitioner of my dispensary during my initial visit and may meet with them on any subsequent visit to obtain additional counseling regarding the use of medical cannabis to meet a treatment goal. By being certified by the physicians at Herbal Care Rx, I acknowledge that I am solely responsible for how, when and where I use cannabis. As such, Herbal Care Rx is unable to provide information to your employer or any other entity regarding your pattern of use of medical cannabis.

Furthermore, I, the undersigned, or anyone acting on my behalf, hold the physician and her principals, agents, and employees, free of and harmless from any liability resulting from the use of medical cannabis.

I further understand that by signing below, I am authorizing the release of any part of this record, except for identifying information, for use in data analysis of medical cannabis treated patients.
ELECTRONIC SIGNATURE CONSENT
I agree that this agreement may be electronically signed. I agree that the electronic signatures appearing on this agreement are the same as handwritten signatures for the purposes of validity, enforceability, and admissibility, in accordance with the Electronic Signatures in Global and National Commerce (ESIGN) Act.
Electronic Signature: By typing your name below, you are supplying your electronic signature and agreement to the above Terms & Conditions. Please type your first and last name using your keyboard (digitally-drawn signatures will not be accepted by the form and you will experience an error).

First Name (Please type using keyboard only)Last Name (Please type using keyboard only)
Electronic Signature: By typing your name below, you are supplying your electronic signature and agreement to the above Terms & Conditions. Please type your first and last name using your keyboard (digitally-drawn signatures will not be accepted by the form and you will experience an error).
First Name*
First Name Only
Last Name*
Last Name

Notice of Privacy Practices

Patient Acknowledgement Authorization for Use/Disclosure of PHI
Acknowledgement of Privacy Notice

I have received the practice’s Notice of Privacy Practices. The Notice provides in detail the uses and disclosures of my Protected Health Information (PHI) that may be made by this practice. I understand that the practice reserves the right to change the terms of its Notice of Privacy Practices, and to make changes regarding all PHI at, or controlled by, this practice. I understand I can obtain this practice’s Notice of Privacy on request.

Patient Manner of Contact

In general the HIPAA Privacy rule gives individuals the right to request a restriction on uses and disclosures of their PHI. I understand that verbal request is an acceptable authorization for the use of any alternate contact method, number and/or location as well as to change in the manner listed below (i.e. if a patient leaves a message with contact number and/or location, other than listed below). I understand that this practice calls to confirm appointments at the number I give.

I understand that by signing this form I am confirming my receipt of the Notice of Privacy Practices; authorization for method of contact, and authorization for use and/or disclosure of my PHI.
Electronic Signature: By typing your name below, you are supplying your electronic signature and agreement to the above Terms & Conditions. Please type your first and last name using your keyboard (digitally-drawn signatures will not be accepted by the form and you will experience an error).

First Name (Please type using keyboard only)Last Name (Please type using keyboard only)
Electronic Signature: By typing your name below, you are supplying your electronic signature and agreement to the above Terms & Conditions. Please type your first and last name using your keyboard (digitally-drawn signatures will not be accepted by the form and you will experience an error).
First Name*
First Name Only
Last Name*
Last Name

Herbal Care Rx Office Policies
Here at Herbal Care Rx, we are dedicated to providing you with the best possible care and services. We have adopted the following financial policies in order to minimize confusion or misunderstanding between our patients and practice.

Payments for services are due two (2) business days before your scheduled telemedical consultation. Herbal Care Rx currently only accepts payment by credit or debit card through our online vendor. At this time, these services are not covered by insurance. Services provided at Herbal Care Rx are self-paid services.

Policy Regarding Attestations of Fitness for Employment or Duties

By choosing Herbal Care Rx as your certifying provider for your medical cannabis card, you acknowledge that Herbal Care Rx is not responsible for how/when/where you use your medicine. As such, we are unable to provide documentation to your employer or other authorities regarding your use of the medicine, or your fitness to perform work duties or other activities. We have a basic letter that we can provide which will explain the PA medical marijuana program and outline our role as your certifying provider. That letter can be personalized for you and provided to you upon request. You also acknowledge that we are not your primary care provider, and are therefore unable to fill out any forms or paperwork requested by your employer, disability agencies, or other authorities. It is appropriate for your primary care provider to fill out any forms about you.

I have read and fully understand the policies of this office and agree to pay for services at least two (2) business days before services are rendered.
Electronic Signature: By typing your name below, you are supplying your electronic signature and agreement to the above Terms & Conditions. Please type your first and last name using your keyboard (digitally-drawn signatures will not be accepted by the form and you will experience an error).

First Name (Please type using keyboard only)Last Name (Please type using keyboard only)
Electronic Signature: By typing your name below, you are supplying your electronic signature and agreement to the above Terms & Conditions. Please type your first and last name using your keyboard (digitally-drawn signatures will not be accepted by the form and you will experience an error).
First Name*
First Name Only
Last Name*
Last Name

Medical Cannabis Patient Declaration
I hereby declare that I have completely and truthfully disclosed all information regarding my medical condition and attest that I do not intend to use my medical recommendation for the purpose of illegally obtaining, growing, or distributing medicinal cannabis.

I am aware that my recommendation/certification can be revoked at any time, and legal action will be taken if I have perjured or misrepresented myself, my condition, or my intentions, or have falsified any medical records given to the physician.

Additionally, I acknowledge that the attending physician has informed me of the nature of the recommended treatment, and addressed any questions I have regarding the risks, complications, and expected benefits of said recommended treatment. I acknowledge that I understand that no guarantee can be made regarding the likelihood of success or failure of treatment with medical cannabis.

I acknowledge the attending physician has informed me of alternatives to the recommended treatment, including the alternative of no treatment, and the associated risks and benefits. The physician may request that I visit another physician or specialist to further substantiate my condition. I will be informed of all of the above regardless of whether or not I qualify as a medical cannabis patient.
Electronic Signature: By typing your name below, you are supplying your electronic signature and agreement to the above Terms & Conditions. Please type your first and last name using your keyboard (digitally-drawn signatures will not be accepted by the form and you will experience an error).

First Name (Please type using keyboard only)Last Name (Please type using keyboard only)
Electronic Signature: By typing your name below, you are supplying your electronic signature and agreement to the above Terms & Conditions. Please type your first and last name using your keyboard (digitally-drawn signatures will not be accepted by the form and you will experience an error).
First Name*
First Name Only
Last Name*
Last Name
If you select yes, you will be redirected to our booking page for you to make a payment and select your preferred appointment time and date.

YesNo
Should be Empty:

Herbal Care Rx Intake Form

Past Medical History

Release of Liability

Notice of Privacy Practices

Herbal Care Rx Office Policies

Medical Cannabis Patient Declaration