Medical Marijuana Intake Form
  • AFFIRM DIRECT PRIMARY CARE

    AFFIRM DIRECT PRIMARY CARE

  • Please complete the documents below

    Medical Marijuana Intake Form- Bennett

    Medical Marijuana Consent- Bennett

  • Medical Marijuana Intake Form

  • Please enter your information.

  • Date of Birth (M/D/YYYY)*
     / /
  • Format: (000) 000-0000.

  • Are you a permanent Florida resident?*
  • Patient Status*
  • How did you learn about Affirm DPC?

  • New Medical Marijuana Patients

  • The next two questions are for New Patients in the Medical Marijuana Program (NEW PATIENTS ONLY)

  • **This information enables us to create your account on the Florida State Medical Marijuana Use Registry.

     

  •  Existing patients in the Medical Marijuana Use Registry

     

  • Card Expiration Date*
     / /
  • Certification Expiration Date*
     / /

  • What brings you in today?

  • How long have you had the conditions about which you are consulting us?*
  • Have your health problems progressed since they began?*
  • How often are you having pain or discomfort?*
  • Do you take any prescription medications, over-the-counter medications, vitamins or any other supplement(s)?*
  • Are you currently under the care of a family physician or any other health*
  • Rows

  • Health

    Please Fill Out
  • Rows
  • Do you smoke? (cigarettes or other substances)*
  • Date Quit*
     / /
  • Drink Alcohol? (cigarettes or other substances)*
  • Date Quit*
     / /
  • Have you ever felt the need to cut down on your drinking?*
  • Currently Use Marijuana?*
  • What Form?*
  • Have Allergies?*
  • What Substance?*
  • How regularly do you follow your ideal routine? (e.g.: go to bed early, eat meals on time, exercise regularly)*
  • Rows
  • Are you postmenopausal?*
  • Are you currently pregnant or could be pregnant?*
  • Do you take contraceptive pills or use other forms of birth control?*
  • Did you experience any abuse or trauma as a child?

  • Please sign I hereby authorize Affirm DPC Practitioner and/or such assistants as may be requested by said physician to review the above-noted medical information provided. I acknowledge that no warranty or guarantee has been made as to the results of this appointment. I understand that any aspect of this consent form that I do not understand can and will be explained to me in further detail by asking the physician.

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