Patient Form
Full Name (EXACTLY AS YOUR ID with full middle name or Dispensary will NOT accept it!)
*
First Name
Middle Name
Last Name
Suffix
Preferred Name to be called if different:
Email
*
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
Street Address Line 2
City
State / Province
Postal / Zip Code
Date of Birth
*
/
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
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?
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 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 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
Pre-Pay (Not required but encouraged) SKIP THIS IF YOU ARE NOT PAYING TODAY. DO NOT CLICK ANYTHING IN THIS SECTION. GO TO SIGNATURE BELOW IF YOU DO NOT WISH TO PREPAY.
prev
next
( X )
Initial Assessment with State Filing
This includes: Evaluation, Certification, Filing, And State Fee
$
200.00
Initial Assessment without State Filing
First time - Only if you do NOT need the state license. If you need the medical card for job protection, legal issues, or plan to travel out of state you MUST still file with the state.
$
150.00
Recertification Unexpired with State Card
Your certification has not expired and you do need the state card.
$
125.00
Recertification Unexpired WITHOUT state card
Your certification has not expired and you do not need the state card for job or legal protections.
$
75.00
Recertification Expired With State Filing
If your certification has expired and you need to renew and want your state card.
$
150.00
Recertification Expired WITHOUT State Card
Your certification has expired and you do not need the state card for job or legal protections.
$
100.00
State Filing Assistance
This includes: My filing your state if you already have a certification from a different provider or chose not to get it at the time of certification / recertification and the state filing fee.
$
75.00
Credit Card
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. I further give The Hybrid Staff permission to act on my behalf for my state card if I chose to sign up for that part.
*
Clear
We have a referral program at The Hybrid Clinic! Who sent you to us? We give a discount to our patients that send us their friends and family. In order to get the discount their name has to be listed when your form is submitted and cannot be added afterwards.
If we have a cancelation, do you want to be contacted sooner?
Yes
No
Notes for Staff: DO NOT WRITE IN THIS SECTION
Submit
Should be Empty: