Simply Sweet Health Medical Marijuana Evaluation Form

Name*

First NameMiddle NameLast Name

Birth Date:*

MonthDayYear

Drivers License or State Issued ID Number*

Required for your medical certificate to be completed

E-mail:*

Phone Number:*

Area CodePhone Number

Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Gender

Are You allergic to any medications?*

NOYES

Do you take any medications?*

NOYES

Please list the allergies you have

Medication and environmental allergies required

Please list the medications you take

Medication and environmental allergies required

Have you been a patient of Nathaniel Arnatt, NP-C previously?*

YesNo

Medical Cannabis Evaluation Agreement and Consent to Treat

Payment must be received prior to the first visit

Please consider using ACH/bank draft option (helps us avoid credit card fees)

Terms and conditions: I ("Patient") hereby authorize SIMPLY SWEET HEALTH, LLC ("Practice") to charge payment method for my telemedicine visit for the charges I incur from services received through the participating healthcare provider, Nathaniel Arnatt, NP-C ("Provider"). I understand that I will remain responsible for these charges, additional late fees, and any other applicable charges if the withdrawal to the bank account is denied for insufficient funds or otherwise becomes unavailable.

Completion of this form does not guarantee services which are provided by Provider at the full descretion and timing of Practice. I attest I am not currently experiencing a medical emergency. I agree if I do have or develop a medical emergency, I will dial 911 and will go to the nearest emergency department.

I authorize Provider on behalf of Practice to assess and diagnose my medical condition.

I consent to methods of non-secure communication which will allow Provider to contact Patient through audio, video, and text.

I understand it is my responsibility to provide all necessary information including signs and symptoms, medical history, and information about the current condition to Provider.

I confirm all information I provide during my telemedicine visit is accurate and true to the best of my knowledge.

I acknoledge there is no guarantee of a particular treatment or prescription. If medical card is denied by Provider for any reason, a full refund will be issued. Refurnds may take up to 7 days to process.

I understand services are provided on a fee-for-service basis and do not constitute a membership agreement.

I acknowledge the potential risks of telemedicine and/or home visits include but are not limited to:

No availability of diagnostic, laboratory, x-ray, and other testing to assist Provider in diagnosis and treatment.
Provider's inability to conduct a hands-on physical examination of me and my condition during a telemedicine visit.
Delays in evaluation and treatment due to Practice schedule and/or due to limited Provider availability.
Delays in evaluation and treatment due to technical difficulties. I will not hold Practice responsible for lost or stolen information due to technological failures.

By signing I hereby agree to abide by the terms and conditions as outlined above and attest that I am a current resident of Virginia and I am at least 18 years of age or older.

Date*

Date

Patient or Parent/Legal Guardian agrees to the terms and conditions by signing below:*

My Products*

Medical Marijuana Card

$100.00

Enter coupon

Total

$0.00

Payment Methods

Credit Card

Apple Pay

Google Pay