MEDICAL CANNABIS PATIENT INTAKE FORM
Confidential – For Medical Use Only
SECTION 1: PATIENT INFORMATION
Full Legal Name:
Date of Birth (DD/MM/YYYY):
-
Month
-
Day
Year
Date
Gender:
Province:
Street Address:
Address Details
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone:
Format: (000) 000-0000.
Email:
example@example.com
Mariceuticals Hemp & Cannabis Corporation
www.mariceuticals.ca
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MARICEUTICALSHEMP AND CANNABIS CORPORATION
SECTION 2: MEDICAL HISTORY
Primary Reason for Requesting Medical Cannabis:
Chronic Pain (Back/Neck/Joint)
Anxiety / PTSD
Sleep Disorder / Insomnia
Inflammation / Arthritis
Other
Current Medications: (Please list all prescription drugs, especially blood thinners or sedatives)
Mariceuticals Hemp & Cannabis Corporation
www.mariceuticals.ca
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MARICEUTICALS
Personal/Family History of Mental Health: Have you or an immediate family member ever been diagnosed with Schizophrenia or Psychosis?
Yes
No
SECTION 3: CANNABIS EXPERIENCE & PREFERENCES
Previous Cannabis Use:
Never
Occasional
Daily
Preferred Method of Consumption:
Oil / Tincture
Capsules
Dried Flower (Vaporization)
Topical (Cream/Ointment)
Mariceuticals Hemp & Cannabis Corporation
www.mariceuticals.ca
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MARICEUTICALSHEMP AND CANNABIS CORPORATION
SECTION 4: ACKNOWLEDGEMENTS & CONSENT
Please initial each point below:
I understand that medical cannabis may cause impairment and I agree not to operate a motor vehicle or heavy machinery while being impaired or intoxicated.
I authorize this clinic/practitioner to share my medical document and registration information with the Licensed Producer of my choice.
I certify that the information provided is true and correct, and I will not use medical cannabis for any illegal purpose or resale.
SECTION 5: SIGNATURE
Patient Signature:
Date:
-
Month
-
Day
Year
Date
Counselor Name:
SECTION 6: PRACTITIONER USE ONLY
License No:
Authorized CBD/THC Limits (if any):
Mariceuticals Hemp & Cannabis Corporation
www.mariceuticals.ca
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