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Registration
If you have any issues filling out the form call us for help. 720-443-2420 English or 720-443-2166 Español
STEP 1: Fill out patient registration form below
STEP 2: Call 720-443-2420 to schedule your appointment.
HCU Screening
Step
1
of
3
33%
Basic Info
Name
(Required)
First
Last
Email
(Required)
SSN
(Required)
DOB
(Required)
MM slash DD slash YYYY
How should we contact you?
(Required)
Email
Cell
Text
Home Phone
US Mail
Status
Single
Married
Divorced
It's Complicated*
Main Phone
(Required)
Secondary
Emergency Contact
Phone
(Required)
Street Address
Address Line 2
City
State
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
ZIP Code
In-Clinic Visit
(Required)
In-Clinic Denver
In-Clinic Loveland
In-Clinic Edwards
In-Clinic Grand Junction
In-Clinic Montrose
In-Clinic Basalt
In-Clinic Glenwood Springs
Visit Type?
(Required)
New to Clinic
Previous Healthy Choices Paitent
Change Plant Count / Homebound status
Consult Only - I don't need a CO Medical Marijuana Registry Card
Do you have Health Insurance?
Yes
No
We do not bill insurance. We do not report any information to your insurance company. We ask for care purposes only.
Are you Pregnant?
(Required)
Yes
No
Are you Home Bound?
Yes
No
Are you unable to leave home without assistance?
Are you requesting more than 6 plants?
Yes
No
If Yes, extra fees apply
Medical History
Qualifying Condition -Check the condition or symptoms you wish to be evaluated for to qualify for a CO Medical Marijuana Card:
(Required)
Severe Pain - Examples: arthritis, migraines, back pain, knee pain, accident recovery, post-operative, etc
Severe Nausea - includes unknown origin, caused by medications, etc
Seizures - includes epilepsy, post-concussion, unknown origin, etc
Persistent Muscle Spasms - includes multiple sclerosis, essential tremor, Tourette's, etc
Cancer
Glaucoma
HIV / AIDS
Cachexia - weight loss with muscle loss, unexplained weight loss
ASD - Autism Spectrum Disorder
PTSD - Post Traumatic Stress Disorder
Want to Use Cannabis Instead of Opiates
Consultation Only - I don't need a CO Medical Marijuana Card
Primary Physician or Diagnosing Care Provider or Mental Health Professional - Name or Clinic Name Required for ASD and PTSD
PCP / Mental Health Pro Phone #
Describe Major Health Issues. Include when and how began, if known. Example: back pain, 3 years, occupational - warehouse work
(Required)
Prior Diagnostic Tests and/or Treatments - check all you've used
(Required)
Diagnosed at Clinic or Hospital by Primary Care Provider, Nurse Practitioner, Physicians Assistant, or other health professional
Imaging: X-ray, MRI, CT scan, etc
Surgery
Chiropractic Care
Massage Theray
Physical Therapy
Acupuncture
Injections: nerve blocks, painkillers, steroids, etc
Counselling / Mental Health Care
Dental work, Facial Pain specialist, dental hygienist
Other
No prior diagnosis or treatments
Medication History
(Required)
Over the counter Pain meds, NSAIDs - Tylenol, Advil, aspirin, etc
Prescription Pain meds including NSAIDs and/or opiates, narcotics
Anxiety meds / Tranquilizers - Xanax, Valium, etc
Muscle relaxers
Sleeping pills
Anti-inflammatory drugs / Steroids
Anti-depressants / Anti-psychotics / Mood stabilizers
Biologics / Immune suppressors
Other medications - list next section
No medications tried
Other Medications Tried
Drug and Food Allergies or Side-effects of RX drugs
(Required)
Current Medications and/or Over the Counter Drugs and Supplements
(Required)
Cannabis Use Information
Do you have Pain?
(Required)
Yes - answer Pain questions
No - go on to next section
Pain Questions
Constant
Episodic - it comes & goes
Both - constant low to moderate pain with episodes of severe pain
Does your condition affect your sleep?
(Required)
Yes - answer Sleep questions
No - go to next section
Sleep Questions
Trouble falling asleep
Trouble staying asleep
Both - trouble falling asleep then wake up several times
Nightmares / vivid dreams / don't feel rested
Wake up in pain / nauseous / anxious
Cannabis Use - Have you used cannabis before?
(Required)
Yes
No - Go to Consent section
If Yes, how long have you been using cannabis?
Pain / PTSD Patients - Pain or Anxiety level WITHOUT Cannabis
Pain / PTSD Patients - Pain or Anxiety level WITH cannabis
Types of Cannabis you use:
Flower / Smoke joints, pipe, or bong
Vaporize with vape pen or volcano
Dabs concentrates
Edibles
Pills or capsules
Tinctures, sodas, or drops under tongue
Balms, salves, lotions, muscle rubs
Patches or gels
Other - bath salts, teas, raw cannabis juice, suppositories, etc
Cannabinoids you use
CBD mostly
THC mostly
Combine CBD & THC
Other - CBG, THCA, etc
Describe your cannabis use for your medical condition - Example: 20mg THC edible at bedtime, CBD rub on knee during day, smoke flower after work
Are you getting adequate relief for your condition with cannabis?
Yes
No
FLOWER - Estimate how much you use per week
EDIBLES - Estimate how much you use per week
CONCENTRATES - Estimate how much you use per week. Includes vape pen cartridges and dabs. MUST be filled out if requesting MED Uniform Certification form for increased concentrate purchase limits.
Where do you get your cannabis?
Shop at Dispensary
Grow / make my own
Caregiver
Δ
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