MD GreenScript Cannabis New Patient Intake Form

New Patient Intake Forms

For New Patients and Recertification
Patient Name*

First Name Last Name
Date of Birth*

Month Day Year
Gender*
Contact Phone Number:*
E-mail Address*
example@example.com
Physical/Home Address:*

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
New Patient or Recertification?*

New Patient (1st Certification)Recertification (Renewal)
MMCC Patient ID Number*
Pxxx-xxxx-xxxx-xxxx (please type in this format) Please make sure you have an active MMCC Medical Card from the state. If you card is expired, please reapply with the MMCC through the OneStop Portal. If you are unsure of your expiration date, please login to your One Stop Account on the MMCC website.
MMCC Card Expiration Date (Printed on your patient ID card) (Please note if your MMCC Medical Card is expired, you will need to renew the card through the MMCC before proceeding with your consultation)*

Month Day Year
Occupation (If Applicable)
Primary Care Provider (If Applicable)
Referred by (If Applicable)
Past Medical History*
Taking any medications, currently?*

YesNo
If yes, please list it here
Reasons for Cannabis Use*
Have you every had surgery?*

YesNo
If yes, please list surgical history here
Do you agree to follow all MMCC Rules and Regulations and HIPAA guidelines?*

YesNo
After clicking submit after completing these forms, please follow the link on the next page to schedule your Consultation for Certification through Square. Do you agree to do this?*

YesNo
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New Patient Intake Forms