First-Time Patient Questionnaire (Form 1 of 3)
Thank you for choosing Vireo Health of New York for your medical cannabis needs. Please fill out this brief questionnaire prior to your consultation. This will allow our Pharmacy team to better assist you.
I am:
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Please Select
a Patient
a Caregiver
Patient First Name:
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Patient Last Name:
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Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Medical Cannabis ID Number
*
Please check all those circumstances that apply:
Breastfeeding/Nursing
Pregnant or possibly pregnant
Personal or direct family history of mental health conditions such as schizophrenia
Feeding tube
Children in home
Other
Do you have any medication or food allergies?
No
Yes, please specify:
What are the symptoms you would like medical cannabis to relieve?
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Nerve pain
Muscle Pain / Spasms
Nausea / Vomiting
Appetite
Sleep
Other
Have you received any medical cannabis products within the last 30 days?
*
Please Select
No
Yes
Please list medications that you are currently taking or any other information you would like our Pharmacy Team to know about:
*
Upload any relevant files you would like our Pharmacy Team to review:
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Name of Person signing form (if not patient)
Referred By (If You Found Vireo Via A Referral)
Signature:
*
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