Disclaimer: Thank you for your interest in being a client of Re-Light Consulting. Information collected about new clients is confidential and will be treated accordingly.

A Registered Caregiver is someone you may appoint to act on your behalf in obtaining medication at the dispensary. If you believe that a caregiver will be necessary, please contact your authorizing physician for registration instructions.

Have you tried cannabis before?YesNo (If no, skip to the next section)

Indicate your preferred forms of cannabis consumption:

Indicate your preferred level of CBD / THC:

Have you experienced negative effects from cannabis?YesNo If yes, what effects?

List your symptoms including the frequency, severity, and duration of pain:

List the type, duration, and outcome of any treatments you have tried:

List the medications you currently take including the dosage and frequency:

If yes, how many cigarettes per day? How many years?

Do you use any other drugs? If yes, what drugs?

How often?

Daily, Weekly, Occasionally, or Rarely?

I acknowledge that I possess specific privacy rights regarding my protected health information as defined by the Health Insurance Portability and Accountability Act (HIPAA) of 1996. I understand that I have the right to review the dispensary's Notice of Privacy Practices prior to signing this form and that the dispensary maintains the right to change the terms of its Notice of Privacy Practices.