Medical Cannabis Intake Form
Please be advised that the $200 fee covers the evaluation and does not guarantee certification.
Name
First Name
Last Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Preferred Contact Method
New Patient Identifier
New to medical cannabis
Transfer from another doctor
Do you have a legal representative or caregiver?
Have you ever been certified by another doctor?
Who is your Primary Care Doctor?
Would you like to become a primary care member at Fresh Start Primary Care? (We cannot accept Medicare patients for primary care services at this time)
What qualifying condition do you have?
Cancer
Epilepsy
Glaucoma
HIV/AIDS
PTSD
Amyotrophic lateral sclerosis (ALS)
Crohn's Disease
Parkinson's Disease
Multiple Sclerosis
Terminal condition diagnosed by another physician
Chronic Pain
Other
If "Other", describe here
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Submit
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