• Charm City Cannabis Cards, a Service of Well Medical Center, PC

    CharmCityCannabis Cards: wellmedicalcenter.com 1-800-368-9607
  • Welcome to Charm City Cannabis Cards
    A Service of Well Medical Center, PC

    Please complete the intake below so we can review your information securely.

  • Don't Have An Appointment?

    Please enter your details below before moving to the next section.

  • Appointment
  • Thank you

    Your intake is nearly complete. Please finish the remaining sections and sign at the end.

  • READY TO DO THIS? 

    START YOUR INTAKE QUESTIONNAIRE & CONSENT FORM NOW!

    Medical Cannabinoid Therapy

    Cannabinoids are compounds found in cannabis (marijuana) that may help manage certain symptoms and conditions.

    Like any treatment, medical cannabinoid therapy has potential benefits and risks. Treatment should be viewed as a trial and continued only if it provides meaningful improvement without unacceptable side effects.

    No specific results can be guaranteed. Please discuss any questions or concerns with your healthcare provider.

    The following are some of the recognized risks for use of this substance:

    1. Psychiatric Disturbance, including but not limited to the development of schizophrenia
    2. Numbness
    3. Speech disorders
    4. Muscle disorders
    5. Drowsiness
    6. Cognitive and Memory Impairment
    7. Short-term memory

    Benefits

    The following are alleged to be the efficacy of marijuana to treat the qualifying conditions, but still require further study. Caveat: there is not much literature for study or very little evidence on these areas that cannabinoids are the cure to these illnesses:

    1. Cancer
    2. Chronic benign pain
    3. Crohn's disease
    4. Epilepsy
    5. Glaucoma
    6. Acquired immune deficiency syndrome
    7. Post-traumatic stress disorder
    8. Amyotrophic lateral sclerosis
    9. Multiple sclerosis
    10. Parkinson's disease

    Laws and Regulations

    There are laws and regulations regarding the use of cannabinoids that your practitioner has to adhere to. The following requests are considered standard best practice and help this healthcare practice, and you comply
    with these laws and regulations.

  • Do you have a history of Muscle Aches/Chronic Pains/Back Pain?
  • Do you have a history of anxiety or panic disorder?
  • Do you have a history of substance abuse?
  • Do you have a history of suicidal thoughts or ideations?
  • Have you ever been diagnosed with schizophrenia, major depression, or other psychosis? If so, which?
  • Do you have a history of thyroid cancer or disease. If so, what type?
  • Have you ever been diagnosed with asthma or bronchitis?
  • If applicable, are you currently pregnant or breastfeeding?
  • Are you on any of the following medicines (SELECT NONE IF NONE OF THESE APPLY TO YOU)?
  • MCA Registration

  • Acknowledgment

    In consideration of being allowed to consume Medical Cannabinoid, I hereby agree that during the period that I am experiencing the side effects of such use, I will not drive any vehicle or operate any heavy machinery within 8 hours.

    I understand that the intake of alcohol is not recommended and dangerous and therefore I shall not take both together.

    I agree to comply with the requirements set forth by the physician and shall not use marijuana in an unregulated manner. I likewise agree to use marijuana only as prescribed by my physician.

    I agree not to give, sell, or share the marijuana with anyone else.

    I agree to store the marijuana in my possession safely, properly, and away from the view of anyone, including children.

    I shall not take the marijuana outside the country, nor should I bring it with me for travel to any other country or state.

    I understand that if in any case my condition worsens or unusual or unknown side effects happen, I shall notify my physician immediately.

  • Date of your scheduled appointment with Charm City Cannabis Cards / Well Medical Center:
     - -
    2 digit month, 2 digit day, 4 digit year
  • Time of your scheduled appointment with Charm City Cannabis Cards / Well Medical Center
  • Browse Files
    Drag and drop files here
    Choose a file
    Cancelof
  • Medical History

  • Birth Date
     - -
    2 digit month, 2 digit day, 4 digit year
  • Age of Consent
  • Format: (000) 000-0000.
  • Payment

  • Have you already paid for your appointment?
  • Date Signed*
     - -
    2 digit month, 2 digit day, 4 digit year
  • My Products

    prevnext( X )
          MMCard NEW
          $150.00$150.00
            
          MMCard RENEWAL
          $99.00$99.00
            
          4/20 Renewals Discount Month!
          $79.00$79.00
            
          Total
          $0.00$0.00

          Payment Methods

          creditcard
          After submitting the form, you will be redirected to Apple Pay to complete the payment.
          After submitting the form, you will be redirected to Google Pay to complete the payment.
          After submitting the form, you will be redirected to Afterpay to complete the payment.
        • Providers: Click here for Registered Patient Page

          https://onestop.md.gov/dashboard/list_views/601c0fd1f9d7557af267bdc4
        • Should be Empty: