West Virginia Medical Cannabis Certification – Patient Intake
Complete this form before your visit with Dr. Arora so we can prepare for your WV certification.
Page 1 – About you
Legal first name
*
Middle name
Legal last name (must match your state ID)
*
Date of birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Email
*
example@example.com
Mobile phone
*
Please enter a valid phone number.
Format: (000) 000-0000.
City and ZIP code
*
West Virginia resident?
*
Yes
No
Age 18 or older?
*
Yes
No
Parent / legal guardian full name
*
Parent / legal guardian phone
*
Please enter a valid phone number.
Format: (000) 000-0000.
Page 2 – Your qualifying condition
Qualifying condition
*
Please Select
Severe chronic or intractable pain of neuropathic origin, or severe chronic or intractable pain
Neuropathies
Post-traumatic stress disorder (PTSD)
Cancer
Damage to the nervous tissue of the spinal cord with objective neurological indication of intractable spasticity
Epilepsy
Crohn's disease
Multiple sclerosis
Parkinson's disease
Terminally ill
Intractable seizures
Amyotrophic lateral sclerosis (ALS)
Huntington's disease
Positive status for HIV/AIDS
Sickle cell anemia
Describe your condition in your own words
*
How long have you had this condition?
*
Please Select
Less than 1 year
1–3 years
3–10 years
More than 10 years
Doctors or clinics that have treated this condition in the past 12 months
*
Medical records or a recent visit note
Upload a File
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Have you ever had a prior medical cannabis certification in any state?
*
Yes
No
Where and when?
*
Page 3 – Health history
Current medications and supplements (include name and dose, including over-the-counter items)
*
Allergies
Other medical or mental health conditions
Current cannabis use
*
Yes
No
Prefer not to say
Alcohol use
*
Please Select
None
Occasional
Weekly
Daily
Does your work involve driving or operating heavy machinery?
*
Yes
No
Are you pregnant, planning pregnancy, or breastfeeding?
*
Yes
No
Not applicable
Page 4 – Your visit
Preferred visit type
*
In person – Barboursville, WV office
Telehealth video visit (West Virginia residents)
Preferred days and times
How did you hear about us?
Please Select
Google
Facebook/Instagram
Friend or family
My doctor
Dispensary
Other
Additional notes for Dr. Arora
Page 5 – Acknowledgements
1. I understand that this physician certification confirms a qualifying condition under the West Virginia Medical Cannabis Act and is not a prescription. I must still apply to the West Virginia Office of Medical Cannabis for a patient identification card.
*
I agree
2. I understand that certification requires an ongoing patient-physician relationship, including at least one visit per year.
*
I agree
3. I authorize Dr. Arora to review medical records from other treating physicians and my profile in the West Virginia Board of Pharmacy Controlled Substance Monitoring Program.
*
I agree
4. I understand the potential effects of cannabis on thinking, driving, and operating machinery; possible interactions with medications and alcohol; and risks during pregnancy and breastfeeding. I agree to discuss these risks during my visit.
*
I agree
5. I agree that I may be contacted by phone, text, or email about my visit.
*
I agree
6. I confirm that I have read the Notice of Privacy Practices and that the information I have provided is true and complete.
*
I agree
Patient (or parent/guardian) e-signature
*
Date signed
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Submit
Submit
Should be Empty: