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CED Clinic Intake Form

CED Clinic Intake Form

🙋‍♀️           Welcome !          🙋‍♂️   
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    CED Clinic FAQ

    Why Is This Form Long?

    We take your health—and cannabis medicine—seriously. This form ensures we understand you as thoroughly as possible to provide the best care.

    What is the purpose of this form?
    This form helps us understand your medical history and experience, and it makes scheduling an appointment easy.

    Where does CED Clinic offer consultations and medical card access?
    We offer consultations worldwide and provide medical card access in Massachusetts, New Hampshire, Vermont, Maine, and Rhode Island.

     

    🥳  Dr. Caplan supports cannabis consultations everywhere in the U.S. and internationally.. 🥳 

     

    How is CED Clinic different from typical "card shops"?
    We provide top-tier industry expertise and genuinely care about our patients, fostering long-term relationships through follow-up consultations and ongoing medical care to enhance health outcomes.

    Is CED Clinic right for me?
    If you're seeking a quick, low-cost card without expert guidance or personalized care, we may not be the right fit for you. Rather, we are pioneering the field of a legitimate Cannabis Medicine specialty! 

    Does CED Clinic accept insurance?
    CED Clinic is considered an "out-of-network" provider by some health insurance companies, and our visits may be eligible for insurance reimbursement.

    What will this form cover?
    1) Medical history
    2) Experience with cannabis
    3) Consumption preferences
    4) Impressions of the cannabis marketplace
    5) General health history

    Can I skip questions on the form?
    Yes, you can skip questions if you prefer.

    What is the refund policy?

    Refunds are issued at the discretion of the CED Clinic staff. While we do not wish to commit anyone to services they do not want, we invest significant time and effort into delivering industry-leading care. We expect professional respect and fairness from our patients, including appropriate compensation for services rendered.

     

    Questions?
    Email info@CEDclinic.com

     

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      FYI:  To save your work and return later: click the disc icon down below 
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    Book & pay for your visit... next slide
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    All services are virtual visits (phone or video)
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    Next:   1) Click Blue "sign document" to complete this form.  2) On the next pop-up, click Green "Book Now" button 3) Scroll down to "Additional Services" & click "follow-up" visit
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    Welcome to CED for Guardians and Pediatric Patients

    CED Clinic serves to educate adult and pediatric consumers about the medical properties and value of cannabis. We help to facilitate appropriate evaluations, and/or state-sponsored certifications, of patients within the Massachusetts Medical Marijuana Program, as well as for Maine, Vermont, Rhode Island, and New Hampshire. CED is an organization dedicated to combating, through education and information, stigmas associated with cannabis. Advances in science, medical research, and modern product controls underscore the ability of medicinal cannabis to be a viable and empowering treatment option for patients. Under Dr. Caplan's supervision, CED Clinic believes that discussions concerning cannabis, and knowledge about its benefits, must be more accessible if the misinformation around cannabis is to be overcome. CED Clinic seeks to shine a light upon research, data, and science that support medicinal cannabis’ beneficial aspects.

    Steps Involved in MA state registration (following the clinic visit)

     

    During the process of participating in the MA state medical program, you will receive an email from the state to confirm that you are a patient. This email will provide instructions for completing the registration process, similar to the information you will receive today. You may expect CED Clinic to guide you every step of the way. We are eager to minimize any friction points you may find within the program.

     

    For pediatric patients: After your visit, there are some required steps to complete for your child's certification to be processed completely and a permanent card mailed to your home for access to the dispensaries. For your child to be considered an active, legal patient, able to use medical cannabis in Massachusetts, both the doctor steps AND the state registration steps must be completed. If you, the parent, do not complete the registration process with the Massachusetts Medical Marijuana Program, your child will not be considered a legal patient in Massachusetts and covered by applicable laws.

    Schedule of Visits for Pediatric Patients:

     

    CED Clinics patients and parents are required to have regular follow-up evaluations every 90 days. Massachusetts requires a bona fide relationship between physician and patient as a foundational component of the law that defines the state Medical Marijuana Program. The CED Clinic schedule is intensive, but it allows us to help ensure that you and your child are both enjoying a productive, healthy introduction to the use of therapeutic cannabis, and so that we can continue the process of sharing crucial knowledge and experience about cannabis treatments. There is still much to learn about the therapeutic use of cannabis with pediatric populations, and CED Pedi is committed to learning from patients as well as the evolving medical literature to ensure a safe, effective, and sustainable pediatric medical cannabis practice. Follow-up visits are encouraged, above and beyond the 4 minimum required. Every child is different and benefits from different oversight. We strive to customize each child and parents' education to individual needs and goals.

     

    Visit 1: Introduction to CED | Basic education | Initial Program Access (Fee, meet Dr Caplan and a second provider)
    Visit 2: 90-day follow up 
    Visit 3: 180-day follow up 
    Visit 4: 270-day follow up 

    Other visits beyond the above minimum are welcome, encouraged and included

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    Please Select
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    Please Select
    • Please Select
    • Afghanistan
    • Albania
    • Algeria
    • American Samoa
    • Andorra
    • Angola
    • Anguilla
    • Antigua and Barbuda
    • Argentina
    • Armenia
    • Aruba
    • Australia
    • Austria
    • Azerbaijan
    • The Bahamas
    • Bahrain
    • Bangladesh
    • Barbados
    • Belarus
    • Belgium
    • Belize
    • Benin
    • Bermuda
    • Bhutan
    • Bolivia
    • Bosnia and Herzegovina
    • Botswana
    • Brazil
    • Brunei
    • Bulgaria
    • Burkina Faso
    • Burundi
    • Cambodia
    • Cameroon
    • Canada
    • Cape Verde
    • Cayman Islands
    • Central African Republic
    • Chad
    • Chile
    • China
    • Christmas Island
    • Cocos (Keeling) Islands
    • Colombia
    • Comoros
    • Congo
    • Cook Islands
    • Costa Rica
    • Cote d'Ivoire
    • Croatia
    • Cuba
    • Curaçao
    • Cyprus
    • Czech Republic
    • Democratic Republic of the Congo
    • Denmark
    • Djibouti
    • Dominica
    • Dominican Republic
    • Ecuador
    • Egypt
    • El Salvador
    • Equatorial Guinea
    • Eritrea
    • Estonia
    • Ethiopia
    • Falkland Islands
    • Faroe Islands
    • Fiji
    • Finland
    • France
    • French Polynesia
    • Gabon
    • The Gambia
    • Georgia
    • Germany
    • Ghana
    • Gibraltar
    • Greece
    • Greenland
    • Grenada
    • Guadeloupe
    • Guam
    • Guatemala
    • Guernsey
    • Guinea
    • Guinea-Bissau
    • Guyana
    • Haiti
    • Honduras
    • Hong Kong
    • Hungary
    • Iceland
    • India
    • Indonesia
    • Iran
    • Iraq
    • Ireland
    • Israel
    • Italy
    • Jamaica
    • Japan
    • Jersey
    • Jordan
    • Kazakhstan
    • Kenya
    • Kiribati
    • North Korea
    • South Korea
    • Kosovo
    • Kuwait
    • Kyrgyzstan
    • Laos
    • Latvia
    • Lebanon
    • Lesotho
    • Liberia
    • Libya
    • Liechtenstein
    • Lithuania
    • Luxembourg
    • Macau
    • Macedonia
    • Madagascar
    • Malawi
    • Malaysia
    • Maldives
    • Mali
    • Malta
    • Marshall Islands
    • Martinique
    • Mauritania
    • Mauritius
    • Mayotte
    • Mexico
    • Micronesia
    • Moldova
    • Monaco
    • Mongolia
    • Montenegro
    • Montserrat
    • Morocco
    • Mozambique
    • Myanmar
    • Nagorno-Karabakh
    • Namibia
    • Nauru
    • Nepal
    • Netherlands
    • Netherlands Antilles
    • New Caledonia
    • New Zealand
    • Nicaragua
    • Niger
    • Nigeria
    • Niue
    • Norfolk Island
    • Turkish Republic of Northern Cyprus
    • Northern Mariana
    • Norway
    • Oman
    • Pakistan
    • Palau
    • Palestine
    • Panama
    • Papua New Guinea
    • Paraguay
    • Peru
    • Philippines
    • Pitcairn Islands
    • Poland
    • Portugal
    • Puerto Rico
    • Qatar
    • Republic of the Congo
    • Romania
    • Russia
    • Rwanda
    • Saint Barthelemy
    • Saint Helena
    • Saint Kitts and Nevis
    • Saint Lucia
    • Saint Martin
    • Saint Pierre and Miquelon
    • Saint Vincent and the Grenadines
    • Samoa
    • San Marino
    • Sao Tome and Principe
    • Saudi Arabia
    • Senegal
    • Serbia
    • Seychelles
    • Sierra Leone
    • Singapore
    • Slovakia
    • Slovenia
    • Solomon Islands
    • Somalia
    • Somaliland
    • South Africa
    • South Ossetia
    • South Sudan
    • Spain
    • Sri Lanka
    • Sudan
    • Suriname
    • Svalbard
    • eSwatini
    • Sweden
    • Switzerland
    • Syria
    • Taiwan
    • Tajikistan
    • Tanzania
    • Thailand
    • Timor-Leste
    • Togo
    • Tokelau
    • Tonga
    • Transnistria Pridnestrovie
    • Trinidad and Tobago
    • Tristan da Cunha
    • Tunisia
    • Turkey
    • Turkmenistan
    • Turks and Caicos Islands
    • Tuvalu
    • Uganda
    • Ukraine
    • United Arab Emirates
    • United Kingdom
    • United States
    • Uruguay
    • Uzbekistan
    • Vanuatu
    • Vatican City
    • Venezuela
    • Vietnam
    • British Virgin Islands
    • Isle of Man
    • US Virgin Islands
    • Wallis and Futuna
    • Western Sahara
    • Yemen
    • Zambia
    • Zimbabwe
    • Other
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    Note regarding residency requirements:
    If a patient resides outside the state of Massachusetts, a certification may be given if the patient is receiving end-of-life, palliative, or cancer care in Massachusetts. We must note if this is the case so that a patient with a residential address outside of Massachusetts may register.

     

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    (discounts available)
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    (for our certification discount, please upload your RMD badge next)
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    ( new employees, a paystub works too! )
    Drag and drop files here
    Select files to upload
    Max. file size: 10.6MB
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    Medical History
    If you are completing this form on behalf of someone else (an adult or pediatric patient) please answer the questions on behalf of the patient.

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    select any that apply
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    (The more we know, the more we can help)
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    (1 visit with 3 concerns = 3 ) OR ( 4 separate visits for 1 concern = 4 )
    1 of 4
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    ( 100% anonymous)
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    Great job!  Over halfway done!    

     
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    For the next 2 questions:

    Over the last 2 weeks, how often have you been bothered by any of the following problems?

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    Standard Cannabis Advisory Information

     

    A) Do not consume intoxicating medicine and drive.  Impaired driving is illegal and as deadly and dangerous as driving drunk

     Operating a vehicle of any kind while consuming cannabis is potentially very dangerous, no matter what your tolerance or comfort level. The effects of cannabis can affect the perception of time and distance, reaction time, focus, concentration, and interpretation of context. Using cannabis and getting behind the wheel of a car is grounds for arrest for DUI, regardless of the current medical or adult-use laws in your state. If you are impaired with any medication in public, whether legal prescriptions or medical cannabis, you can be arrested for DUI. If impaired, always choose the safe way. The risk to you and others is never worth it.

    B) If you drive or operate machinery while impaired by any medication or drug, even if they are legal, you can be arrested for DUI, face jail time and fines, and may injure yourself or others.

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    Useful information for patients and caregivers:

    Know the laws, and know your rights

    How many patients can personal caregivers serve?

    An individual may serve as a personal caregiver for only one registered, qualifying patient at a time, except in the case of:
    1) An employee of a hospice provider, nursing facility, or medical facility providing care to a qualifying patient admitted to or residing at, that facility.
    2) A visiting nurse, home health aide, personal care attendant, or an immediate family member of more than one registered qualifying patient.

    What can a patient or caregiver do with the cannabis they legally possess?

    This is taken from the official Massachusetts “Guidance for Law Enforcement Regarding the Medical Use of Marijuana”

    Cannabis that is acquired or grown for a specific registered patient may be used only by that registered patient for medical purposes.

    Patients and their caregivers are prohibited from selling, bartering with, sharing, or otherwise distributing their medical cannabis products to anyone else.

    As a medical patient in Massachusetts, it is ILLEGAL to do the following:

    1) To divert or “re-sell” your medication to others. Your medication is meant for you or your patient as a caregiver.
    2) Use a delivery service or any “dispensary” that has not been licensed by the Massachusetts Department of Public Health. You, the patient, are responsible for knowing legal vs illegal dispensaries.
    3) For caregivers, it is illegal for you to grow for more than one patient or sell medication for anyone other than your one registered patient or family member(s).

    Patient safety is always our most important message, from consumption to acquiring medicine.

     

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    Please read the following and sign below to indicate that you understand and acknowledge the information written. 

    1) Medical cannabis is used to treat debilitating medical conditions, defined as limiting life activities

    2) The use of cannabis affects coordination and cognition, and impairs ability to drive or engage in potentially hazardous activities. Wait at least 6 hours after cannabis use before operating any equipment.

    3) Some patients may experience symptoms when they stop using cannabis. These include irritability, insomnia, loss of appetite, restlessness, trouble concentrating and fatigue.

    4) Cannabis potency varies with the strain and the method of consumption. Determining the appropriate cannabis dosage is difficult and may require a trial-and-error approach. Always start at the lowest dose and increase it gradually.

    5) Nausea, palpitations and numbness are symptoms of cannabis excess. Chronic misuse of cannabis may lead to general apathy in some patients, or to psychosis in those who are predisposed.

    6) Cannabis should not be used if you become pregnant or are breastfeeding.Possession of cannabis is still currently illegal under federal law. CED Clinic clinicians and staff are neither prescribing nor dispensing cannabis. Our certification is that a qualifying medical condition exists and that the potential benefits of medical marijuana appear to outweigh the risks.

    7) CED Clinic clinicians and staff are addressing specific aspects of a patient’s medical care. Unless requested and established through formal acceptance into the CED Clinic clinical practice, they are in no way establishing themselves as a primary care provider. Anonymized responses provided in this form may be used to educate or for research purposes or to improve the quality of cannabis care that we provide.

    8) Cannabis is not regulated by the Food and Drug Administration and may contain unknown quantities of active ingredients and impurities, although the state testing aims to minimize this possibility

    9) Smoking cannabis (with flame) may cause respiratory illness, including cancer. Any ill effects experienced with the use of cannabis require discontinuation of the product and immediate medical evaluation.

    10) A vaporizer substantially reduces many of the harmful toxins that are present in cannabis smoke. Avoiding flame use with cannabis is strongly recommended. Oral cannabis and topical preparations are known to be associated with fewer toxins.

    11) CED Clinic may periodically share communications, including via email, to provide updates on risks or relevant educational information, ensuring our patients remain informed and knowledgeable.

    12) CED Clinic refunds are issued at the discretion of the CED Clinic staff. While we do not wish to commit anyone to services they do not want, we invest significant time and effort into delivering industry-leading care. We expect professional respect and fairness from our patients, including appropriate compensation for services rendered.

     

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    I have read, understood, and accept the above.
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    Experience With Cannabis


    Thank you for helping us to learn about your perspective. The more we learn from your views, the better able we are to educate ourselves and the industry.

    All information below is de-identified and retained as anonymous.

    If you are completing the form on behalf of a pediatric patient, please answer from their point of view.

     

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    Cannabis experience

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    Cannabis impressions & expectations

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    (can be named or anonymous)
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    If you have not paid for this service and wish to, please email info@CEDclinic.com for a separate invoice
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    1) a photo of your license & (2) a photo of proof of residency (car registration, utility bill etc). We will email you an invoice later, by email
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    Thank you for sharing your history, views, and perspective!

     

    Hit "Submit" to complete your form and to book your appointment.

     

    Next, this form should automatically jump you to our booking page found here:

     

    CEDclinic Booking

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