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Certification Intake Form

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     FAQ

    Why Is This Form Long?

    We take your health—and cannabis medicine—seriously. This form ensures we understand you as thoroughly as possible to provide the best care.

    What is the purpose of this form?
    This form helps us understand your medical history and experience, and it makes scheduling an appointment easy.

    Where do you offer consultations and medical card access?
    We offer consultations worldwide and provide medical card access in Massachusetts

     Is this right for me?
    If you're seeking a quick, low-cost card without expert guidance or personalized care, we might be a good fit for you. 

    Does you accept insurance?
    No insurance is accepted. 

    What will this form cover?
    1) Medical history
    2) Experience with cannabis
    3) Consumption preferences
    4) Impressions of the cannabis marketplace
    5) General health history

    Can I skip questions on the form?
    Yes, you can skip questions if you prefer.

    What is the refund policy?

    Rescheduling - You may reschedule your appointment one time. Message us through the assistant (bottom right), or leave your phone number or email, and we'll help find a new time.

    Transferring your evaluation - If you can't use your paid appointment, you may transfer it to someone else instead of rescheduling it yourself. Contact us with the new patient's information before the scheduled time.

    Refunds - The $50 evaluation fee is non-refundable under all circumstances, including cancellations, missed appointments, and evaluations where certification is not issued. Your one allowed reschedule, or the option to transfer your appointment to someone else, applies in place of a refund.

    Missed appointments - If you miss your scheduled appointment, you may still use your one allowed reschedule to book a new time, provided you haven't already used it. The fee is not refunded.

     

     

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    Massachusetts requires both a doctor certification and a state registration.
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    1) a photo of your license & (2) a photo of proof of residency (car registration, utility bill etc). We will email you an invoice later, by email
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    Note regarding residency requirements:
    If a patient resides outside the state of Massachusetts, a certification may be given if the patient is receiving end-of-life, palliative, or cancer care in Massachusetts. We must note if this is the case so that a patient with a residential address outside of Massachusetts may register.

     

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    Medical History
    If you are completing this form on behalf of someone else (an adult or pediatric patient) please answer the questions on behalf of the patient.

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    select any that apply
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    (The more we know, the more we can help)
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    Here, upload any medical records you'd like to discuss or have reviewed. Skip if you have none
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    Max. file size: 10.6MB
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    (1 visit with 3 concerns = 3 ) OR ( 4 separate visits for 1 concern = 4 )
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    For the next 2 questions:

    Over the last 2 weeks, how often have you been bothered by any of the following problems?

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    Standard Cannabis Advisory Information

     

    A) Do not consume intoxicating medicine and drive.  Impaired driving is illegal and as deadly and dangerous as driving drunk

     Operating a vehicle of any kind while consuming cannabis is potentially very dangerous, no matter what your tolerance or comfort level. The effects of cannabis can affect the perception of time and distance, reaction time, focus, concentration, and interpretation of context. Using cannabis and getting behind the wheel of a car is grounds for arrest for DUI, regardless of the current medical or adult-use laws in your state. If you are impaired with any medication in public, whether legal prescriptions or medical cannabis, you can be arrested for DUI. If impaired, always choose the safe way. The risk to you and others is never worth it.

    B) If you drive or operate machinery while impaired by any medication or drug, even if they are legal, you can be arrested for DUI, face jail time and fines, and may injure yourself or others.

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    Useful information for patients and caregivers:

    Know the laws, and know your rights

    How many patients can personal caregivers serve?

    An individual may serve as a personal caregiver for only one registered, qualifying patient at a time, except in the case of:
    1) An employee of a hospice provider, nursing facility, or medical facility providing care to a qualifying patient admitted to or residing at, that facility.
    2) A visiting nurse, home health aide, personal care attendant, or an immediate family member of more than one registered qualifying patient.

    What can a patient or caregiver do with the cannabis they legally possess?

    This is taken from the official Massachusetts “Guidance for Law Enforcement Regarding the Medical Use of Marijuana”

    Cannabis that is acquired or grown for a specific registered patient may be used only by that registered patient for medical purposes.

    Patients and their caregivers are prohibited from selling, bartering with, sharing, or otherwise distributing their medical cannabis products to anyone else.

    As a medical patient in Massachusetts, it is ILLEGAL to do the following:

    1) To divert or “re-sell” your medication to others. Your medication is meant for you or your patient as a caregiver.
    2) Use a delivery service or any “dispensary” that has not been licensed by the Massachusetts Department of Public Health. You, the patient, are responsible for knowing legal vs illegal dispensaries.
    3) For caregivers, it is illegal for you to grow for more than one patient or sell medication for anyone other than your one registered patient or family member(s).

    Patient safety is always our most important message, from consumption to acquiring medicine.

     

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    Please read the following and sign below to indicate that you understand and acknowledge the information written. 

    1) Medical cannabis is used to treat debilitating medical conditions, defined as limiting life activities

    2) The use of cannabis affects coordination and cognition, and impairs ability to drive or engage in potentially hazardous activities. Wait at least 6 hours after cannabis use before operating any equipment.

    3) Some patients may experience symptoms when they stop using cannabis. These include irritability, insomnia, loss of appetite, restlessness, trouble concentrating and fatigue.

    4) Cannabis potency varies with the strain and the method of consumption. Determining the appropriate cannabis dosage is difficult and may require a trial-and-error approach. Always start at the lowest dose and increase it gradually.

    5) Nausea, palpitations and numbness are symptoms of cannabis excess. Chronic misuse of cannabis may lead to general apathy in some patients, or to psychosis in those who are predisposed.

    6) Cannabis should not be used if you become pregnant or are breastfeeding.Possession of cannabis is still currently illegal under federal law. Your clinicians and staff are neither prescribing nor dispensing cannabis. Our certification is that a qualifying medical condition exists and that the potential benefits of medical marijuana appear to outweigh the risks.

    7) Your clinicians and staff are addressing specific aspects of a patient’s medical care. Unless requested and established through formal acceptance into a clinical practice, they are in no way establishing themselves as a primary care provider. Anonymized responses provided in this form may be used to educate or for research purposes or to improve the quality of cannabis care that we provide.

    8) Cannabis is not regulated by the Food and Drug Administration and may contain unknown quantities of active ingredients and impurities, although the state testing aims to minimize this possibility

    9) Smoking cannabis (with flame) may cause respiratory illness, including cancer. Any ill effects experienced with the use of cannabis require discontinuation of the product and immediate medical evaluation.

    10) A vaporizer substantially reduces many of the harmful toxins that are present in cannabis smoke. Avoiding flame use with cannabis is strongly recommended. Oral cannabis and topical preparations are known to be associated with fewer toxins.

    11) We may periodically share communications, including via email, to provide updates on risks or relevant educational information, ensuring our patients remain informed and knowledgeable.

    12)  What is the refund policy?

    Rescheduling - You may reschedule your appointment one time. Message us through the assistant (bottom right), or leave your phone number or email, and we'll help find a new time.

    Transferring your evaluation - If you can't use your paid appointment, you may transfer it to someone else instead of rescheduling it yourself. Contact us with the new patient's information before the scheduled time.

    Refunds - The evaluation fee is non-refundable under all circumstances, including cancellations, missed appointments, and evaluations where certification is not issued. Your one allowed reschedule, or the option to transfer your appointment to someone else, applies in place of a refund.

    Missed appointments - If you miss your scheduled appointment, you may still use your one allowed reschedule to book a new time, provided you haven't already used it. The fee is not refunded.

     

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    I have read, understood, and accept the above.
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    Experience With Cannabis


    Thank you for helping us to learn about your perspective. The more we learn from your views, the better able we are to educate ourselves and the industry.

    All information below is de-identified and retained as anonymous.

    If you are completing the form on behalf of a pediatric patient, please answer from their point of view.

     

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    Cannabis impressions & expectations

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