Vireo Patient Intake, HIPAA Authorization & Consent Form

Vireo Patient Intake, HIPAA Authorization & Consent Form

Please complete all required information before your consultation.
Page 1 — Patient Information
Full Name

First NameMiddle NameLast Name
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
example@example.com
Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Page 2 — Medical History
Medical Screening

Other
If yes, please explain
Allergies (Many Cannabis tinctures and edibles contain MCT (Coconut) oil)
Primary Qualifying Condition
Treatment Goals
Symptoms

Other
If yes, please explain
Page 3 — Medication History
Current Medications
Previous Cannabis Use
If yes, please explain
Page 4 — Provider Information
Referring Provider
Caregiver Information
Page 5 — HIPAA Authorization
I authorize Vireo Health to communicate with my healthcare providers regarding my treatment.
I authorize Vireo Health to leave appointment reminders and treatment information via phone, text message, email, or voicemail.
Authorized Recipient(s)

I have discussed my treatment plan with my healthcare practitioner. I voluntarily choose to participate in treatment and assume responsibility for my use of medical marijuana products. I understand medical marijuana products are intended only for the registered patient and may not be transferred to another person.
I understand medical marijuana may impair my ability to drive or operate machinery.
I understand side effects may include: dizziness; drowsiness; anxiety; memory impairment; impaired coordination; increased heart rate. I understand dependence and withdrawal symptoms may occur. I acknowledge that I have received educational information regarding the risks, benefits, limitations, and possible side effects of medical marijuana treatment.
I agree to notify my healthcare provider of significant changes in my condition.
I understand that outcomes cannot be guaranteed and that medical marijuana products have not been approved by the United States Food and Drug Administration.
To the extent permitted by law, I release Vireo Health, its employees, agents, and affiliates from claims arising from the lawful dispensing and use of medical marijuana products.