MD GreenScript Cannabis New Patient Intake Form

Patient Name*

First NameLast Name

Date of Birth

MonthDayYear

Gender*

Contact Phone Number:*

Format: (000) 000-0000.

E-mail Address*

example@example.com

Physical/Home Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

New Patient or Recertification?*

New Patient (1st Certification) - $100Recertification (Renewal) - $65

MCA Patient ID Number (Please enter your patient ID number correctly. If your number is not included, your appointment will be cancelled)*

Pxxx-xxxx-xxxx-xxxx (please type in this format) Please make sure you have an active MCA Medical Card from the state. If you card is expired, please reapply with the MCA through the OneStop Portal. If you are unsure of your expiration date, please login to your One Stop Account on the MCA website. If your card is inactive, you will not be contacted until you renew through the state

MCA Card Expiration Date (You can find this date through your Onestop Account through the MCA website. Please note if your MCA Medical Card is expired, you will need to renew the card through the MMCC before proceeding with your consultation)*

MonthDayYear

Occupation (If Applicable)

Primary Care Provider (If Applicable)

Referred by (If Applicable)

Past Medical History (Previous or Current Medical Problems)*

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 MCA Rules and Regulations and HIPAA guidelines?*

YesNo

In order to schedule an appointment for you medical certification consultation, please follow the link on the next page . Do you understand this? If an appointment is not scheduled, you will not be contacted.*

YesNo

Again, once you hit submit on these forms, there will be a link on the next page to schedule your appointment with a provider through Square. Please do not ignore this step. Do you understand?*

YesNo

Please add our business number 443-420-7012 to your phone contacts so you receive all of our messages.

New Patient Intake Forms