MD GreenScript Cannabis New Patient Intake Form

New Patient Intake Forms

For New Patients and Recertification
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 (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)*
YesNo
If yes, please list it here
Reasons for Cannabis Use*
YesNo
If yes, please list surgical history here
YesNo
YesNo
YesNo
Should be Empty:

New Patient Intake Forms