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:*
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
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. If your card is inactive, you will not be contacted until you renew through the state
MMCC Card Expiration Date (You can find this date through your Onestop Account through the MMCC website. Please note if your MMCC 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 MMCC 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
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New Patient Intake Forms