(THC) Patient Form

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. The patient form is REQUIRED and on my website under "patient forms" (EVEN FOR RECERTIFICATION!)
**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.***
You MUST still book an appointment after submitting this form. Please make sure this is done from my website! www.TheHybridClinic.com
Full Name (EXACTLY AS YOUR ID or the Dispensary will NOT accept it!)*

First NameMiddleLast NameSuffix
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 or City of Which you Pay Taxes

CityState

Zip Code
Date of Birth (If under 18 please stop and ask for the pediatric form)*

MonthDayYear
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?*

YesNoNo, 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)*

YesNoIn 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?

AlcoholPrescribed medication (any prescribed medication)Benzodiazepines (Xanax, Klonopins)Narcotic pain medicationHeroinMethCocaine
What is your main reason for obtaining your medical card?*

Dispensary AccessJob protectionQualitySeeking new option for my healthHelp stop harder drugsDecrease pharmaceutical pillsDecrease my alcohol consumptionProbation / ParoleCPS / Legal IssuesScared to buy from street
What is your preferred method to consume or want more information about?*

Flower (smoking)CartridgeGummiesTinctureTabletsRosinTopicalOther
What would you consider your knowledge on cannabis?*

NoneVery littleAverageExpert
Preferred method for us to contact you:*

Phone callTextEmail
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?*

YesNot 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)

Cancelof

My Products

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

Enter coupon

Total

$0.00

Payment Methods

Credit Card

Apple Pay

Google Pay

Cash App Pay

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. *

Clear
We have a referral program at The Hybrid Clinic! If you are new to our office, who sent you to us? We give a $10 discount to that person that sent you! Be sure to send your friends to take advantage of this discount.
Notes for Staff: DO NOT WRITE IN THIS SECTION
Once you hit submit, you will get an email of confirmation. If you do not get this email, you did not complete the form properly. This is HIPAA compliant so it will NOT save your information, please make sure it is all correct or you will have to redo it from the start!
Should be Empty:

Patient Form

**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.***

Payment Methods

Once you hit submit, you will get an email of confirmation. If you do not get this email, you did not complete the form properly. This is HIPAA compliant so it will NOT save your information, please make sure it is all correct or you will have to redo it from the start!

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.*