Patient Form
PLEASE READ THE ENTIRE FORM. YOUR NAME MUST MATCH YOUR DRIVER'S LICENSE / ID OR THE DISPENSARY WILL NOT ACCEPT IT!!! Also, you do NOT have to prepay on this form; however, it is easier for you to do so. IF YOU DO NOT want to prepay SKIP that ENTIRE section of the form. IF YOU CHECK ANY BOX IN THAT SECTION IT WILL MAKE YOU PAY. If you do NOT follow directions you will have to repeat the completion of this form. Please allow time to complete all required fields. Once you start the application, please do not refresh or click the back button on this page. ***If you or the patient is under 18 years old please STOP and ask my office for the pediatric form as it is different than this one.***
Full Name (EXACTLY AS YOUR ID or the Dispensary will NOT accept it!)
*
First Name
Last Name
Suffix
Preferred Name to be called if different:
Email (IF THIS IS NOT CORRECT YOU WILL NOT GET YOUR EMAIL FROM THE STATE!!!)
*
example@example.com
Driver's License Number (REQUIRED for Certification)
*
Social Security Number (ONLY if filing state): (The state card is not required in Virginia; however, if you need job or legal protections you may want to do that option)
Address (Including City and Zip)
*
Street Address
County of Which you Pay Taxes
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Date of Birth (If under 18 please stop and ask for the pediatric form)
*
/
Month
/
Day
Year
Date
Phone Number
*
Please enter a valid phone number.
Current medications:
*
Medical Condition(s): (you cannot leave this blank)
*
Allergies:
*
Have you had a medical marijuana cards in Virginia?
*
Yes
No
No, another state
Have you ever been denied or had a medical card revoked?
*
Yes (If Yes, STOP, and please contact the office)
No
Do you currently consume cannabis? (This helps guide my consult)
*
Yes
No
In the past
If you currently consume cannabis, how does it affect your medical condition listed above, if so how?
If you currently consume cannabis, does it decrease your use of any of the following?
Alcohol
Prescribed medication (any prescribed medication)
Benzodiazepines (Xanax, Klonopins)
Narcotic pain medication
Heroin
Meth
Cocaine
What is your main reason for obtaining your medical card?
*
Dispensary Access
Job protection
Quality
Seeking new option for my health
Help stop harder drugs
Decrease pharmaceutical pills
Decrease my alcohol consumption
Probation / Parole
CPS / Legal Issues
What is your preferred method to consume or want more information about?
*
Flower (smoking)
Cartridge
Gummies
Tincture
Tablets
Rosin
Topical
Other
What would you consider your knowledge on cannabis?
*
None
Very little
Average
Expert
Preferred method for us to contact you:
*
Phone call
Text
Email
Please take picture of your FRONT of your UNEXPIRED ID or Driver's license. (It is required for the state to prover your age) If you have an out of state ID you MUST upload an official bill (electric, phone, medical) with your name and VA address down below in supporting uploads.
*
If requesting state card: Do you authorize The Hybrid Clinic to process your paperwork and account on your behalf?
*
Yes
Not Filing for State Card
Upload any supporting medical documents (If you are a recertification from a different provider (The Hybrid Clinic did NOT do your last certification) you MUST upload your previous certification or state card) (State card, certification, medical records)
Browse Files
Drag and drop files here
Choose a file
Cancel
of
****************************************SKIP THIS IF YOU ARE NOT PAYING TODAY. DO NOT CLICK ANYTHING IN THIS SECTION. IF YOU HAVE A GIFT CARD SKIP THIS SECTION!! GO TO SIGNATURE BELOW IF YOU DO NOT WISH TO PREPAY. YOUR EXPIRATION DATE IS 365 DAYS FROM THE DATE ON THE BOTTOM RIGHT OF YOUR CERTIFICATION NOT YOUR CARD!!!
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( X )
Initial Assessment
For patients that are seeking first time medical cannabis status in Virginia.
$
150.00
Recertification Unexpired
Recertification that has not expired. (Expiration is the date in which the last certification was written.)
$
75.00
Recertification Expired
Recertification that has expired. (Expiration is the date in which the last certification was written.)
$
100.00
Payment Methods
Credit Card
Apple Pay
After submitting the form, you will be redirected to Apple Pay to complete the payment.
Google Pay
After submitting the form, you will be redirected to Google Pay to complete the payment.
Cash App Pay
After submitting the form, you will be redirected to Cash App Pay to complete the payment.
I certify by entering my electronic signature below: I am the person applying for licensure/certification/registration. Further, I certify the information provided in this application has been personally provided and reviewed by me, and that statements made on the application are true and complete. I understand that providing false or misleading information, as well as omitting information, in response to information requested in this application or as part of the application process is considered falsification of the application and may be grounds for denial of or taking disciplinary action against an existing license/certificate/registration.
*
We have a referral program at The Hybrid Clinic! Who sent you to us? We give a $10 discount to the person that sent you to us if you are new to The Hybrid Clinic.
If we have a cancelation, do you want to be contacted sooner?
Yes
No
Notes for Staff: DO NOT WRITE IN THIS SECTION
Submit
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