VIRTUAL Beach Health Center Patient Forms

(VIRTUAL) Beach Health Center Patient Intake Form

MAINE MEDICAL CANNABIS CERTIFICATES FOR MAINE RESIDENTS 18 YEARS OLD OR OLDER WITH A VALID MAINE STATE DRIVERS LICENSE OR ID - MED CARDS ARE PROCESSED MONDAY - FRIDAY 10AM - 6PM, SATURDAYS NOON - 6PM, CLOSED SUNDAYS. -Virtual applications are always $50 there is no tax.
Patient LEGAL Name as seen on your ID, please recheck your name for accuracy*

First NameLast Name
Patient Birth Date MM/DD/YYYY*

MonthDayYear
DATE OF BIRTH MM/DD/YYYY*

MonthDayYear
Date
Phone Number -

Area CodePhone Number
PHONE NUMBER (INCLUDING AREA CODE) - WE WILL TEXT THE DIGITAL MED CARD TO THIS NUMBER - PLEASE RE CHECK FOR ACCURACY *
YOUR CELL NUMBER
Mailing Address - your actual mailing address for the physical med card to be sent to*

Street Address

apartment or unit if needed

CityState / Province

Postal / Zip Code
Patient E-Mail*
Patient Medical History
Do you have any of the following conditions/symptoms? (Please check all that apply) - OPTIONAL

Anxiety DisorderMuscle crampsNauseaAnorexiaPainPTSDCron's DiseaseFibromyalgiaInsomnia - SLEEPLESSNESSHeadachesCancerSeizuresMultiple SclerosisDEPRESSIONARTHRITISGLAUCOMAOther
Please attach your VALID MAINE STATE DRIVERS LICENSE OR MAINE STATE ISSUED ID. WE ACCEPT PAPER MAINE LICENSE AS WELL (MUST HAVE A VALID ISSUE AND EXPIRATION DATE)*

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WE CANNOT ACCEPT PASSPORTS, PASSPORT CARDS, MAIL, REGISTRATIONS, INSURANCE, OUT OF STATE LICENSE OR ANYTHING OTHER THAN THE MAINE STATE LICENSE OR ID. ONLY MAINE STATE LICENSE OR ID IS ACCEPTABLE FOR A MEDICAL CARD IN MAINE. PASSPORTS AND PASSPORT CARDS ARE FEDERAL IDENTIFICATION, CANNABIS IS FEDERALLY ILLEGAL. MAINE MEDICAL PROGRAM IS A STATE PROGRAM AND AS SUCH ONLY A VALID MAINE STATE LICENSE OR ID IS ACCEPTED. IF YOU DO NOT HAVE THAT DO NOT GO ANY FURTHER ON THIS FORM. IF YOU ARE REJECTED DO TO THIS SECTION YOU WILL FORFIT $1.75 (SQUARES PROCESSING FEE) AND IT TAKES 5-7 DAYS TO GET YOUR MONEY BACK FROM SQUARE. IF YOU ARE UNSURE ABOUT WHAT YOU ARE ABOUT TO UPLOAD TEXT US AT 207-229-4492 AND ASK US. Cancelof
Patient Agreement & Consent

* Please sign below that you have read, understood, and answered the above questions truthfully to the best of your knowledge. Please be advised that payment for all services will be taken at the bottom of this form. You will receive a text within 2 hours with your digital med card. Please check your phone number and email address before submission to ensure you get your card in a timely manner.
Please read and check each item:*

I hereby declare that I have truthfully and completely filled out this form.I understand that Beach Health Center will not send my medical information or card status to anyone unless I send a written request to do soThe Maine Medical Cannabis Program is protected by the medical privacy act - HIPAA. I understand that no one knows I have a Maine Medical Cannabis Card unless I tell them or show them my card. I understand that there is no registry in Maine.I attest that I have attached a valid Maine state license or ID that is in my possession and is not revoked, surrendered, or lost.I understand that applications are processed Monday - Friday 10am - 6pm, Saturdays Noon - 6pm, with-in 2 hours. Submissions 6pm or after will be processed the next business day, anything 6pm or after on Saturday or anytime Sunday will be processed Monday.I understand that the physical medical card will be mailed to me (unless I choose digital only). there is no pick up available.
Patient Signature*

Clear
Today's Date*

MonthDayYear
Date
How would you like to be notified next year that your renewal is coming due? you may choose more than one

emailmailnone

My Products

VIRTUAL Application Maine Medical Cannabis Certificate$50.00

Must be 18+. Must have a Maine state license or identification card (temporary paperwork is not acceptable must be a valid card). No medical documentation needed. Nurse Practitioner on site for video call certifications.

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Total $0.00

Credit Card

DO YOU WANT A PHYSICAL CARD MAILED TO YOU?*

DO NOT MAIL MY PHYSICAL MED CARD, I ONLY WANT THE DIGITAL CARD THAT IS TEXTED TO MEmail the card to me
IF YOUARE WAITING AT A DISPENSARY, PLEASE LET US KNOW WHAT DISPENSARY YOU ARE AT BELOW (OPTIONAL JUST FOR OUR INFORMATION)
PLEASE NOTE, SUBMISSIONS 6PM OR AFTER ARE PROCESSED THE NEXT DAY. SUBMISSIONS 6PM OR AFTER ON SATURDAYS OR ANYTIME SUNDAY ARE PROCESSED THE FOLLOWING MONDAY
CLOSED EARLY SATURDAY 10.4.25 AT 5:30PM

SUBMISSIONS 5:30 OR AFTER WILL BE PROCESSED BETWEEN NOON - 3 PM SUNDAY 10.5.25
SATURDAY 11.29.25 CLOSING AT 5PM.

SUBMISSIONS 5PM OR AFTER ON SATURDAY 11.29.25 OR ANYTIME SUNDAY WILL BE PROCESSED ON MONDAY 12.1.25
WE ARE GOING TO TEXT YOUR CARD TO YOU, CHECK THE NUMBER YOU PROVIDED
DO YOU HAVE A COUPON CODE? ENTER IT BEFORE SUBMITTING. COUPONS CANNOT BE ADDED AFTER PAYMENT
HOLLIDAY NOTICE:

CLOSED FOR CHRISTMAS. SUBMISSIONS 6PM OR AFTER ON 12.24.25 AND ANYTIME ON THURSDAY CHRISTMAS 12.25.25 WILL BE PROCESSED FRIDAY 12.26.25
KNOWN DELAYS. BELOW ARE THE DAYS/TIMES THAT WE KNOW THERE ARE DELAYS PROCESSING APPLICATIONS (DUE TO TRAVEL AND SET UP FOR IN PERSON LOCATIONS):

MONDAYS 3PM - 4PM, TUESDAYS 11AM - NOON, WEDNESDAYS 2PM - 3PM, THURSDAYS 11AM - NOON, FRIDAYS 11AM - NOON AND 3PM - 4PM.
Should be Empty:

(VIRTUAL) Beach Health Center Patient Intake Form

Patient Medical History

Patient Agreement & Consent

Credit Card

CLOSED EARLY SATURDAY 10.4.25 AT 5:30PM

SATURDAY 11.29.25 CLOSING AT 5PM.

WE ARE GOING TO TEXT YOUR CARD TO YOU, CHECK THE NUMBER YOU PROVIDED

DO YOU HAVE A COUPON CODE? ENTER IT BEFORE SUBMITTING. COUPONS CANNOT BE ADDED AFTER PAYMENT

HOLLIDAY NOTICE:

KNOWN DELAYS. BELOW ARE THE DAYS/TIMES THAT WE KNOW THERE ARE DELAYS PROCESSING APPLICATIONS (DUE TO TRAVEL AND SET UP FOR IN PERSON LOCATIONS):