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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.
Page 1
Page 2
Order Number
First Name
*
Last Name
*
Middle
Social Security Number (no dashes)
*
Status
Single
Married
Divorced
Other
DOB
*
Main Phone
*
2nd Phone
Email
*
Mailing Address
*
City
*
County
*
Zip
*
How should we contact you?
*
Email
Cell
Text
Home Phone
US Mail
Online or In-Clinic Visit?
*
Online Visit - On your computer, tablet, or smart phone
In-Clinic Denver
In-Clinic Loveland
In-Clinic Edwards
In-Clinic Grand Junction
In-Clinic Montrose
Occupation
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?
*
Yes
No
How did you hear about us?
Visit Type?
*
New Patient
Renewal
Change Plant Count / Homebound status
Consult Only - I don't need a Colorado Medical Marijuana Registry Card
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
Emergency Contact:
Phone
Check the condition or symptoms below you wish to be evaluated for to qualify for a Colorado Medical Marijuana Card:
*
Severe pain - Examples: arthritis, migraines, back pain, knee pain, accident recovery, post-operative, etc
Severe nausea - includes unknown origin, caused by other medications, etc
Seizures - including epilepsy
Persistent Muscle Spasms - Including multiple sclerosis, essential tremor, etc.
Cancer
Glaucoma
HIV /AIDS
Cachexia - weight loss with muscle 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 MM Registry Card
Primary Physician or Mental Health Professional (Required for PTSD and ASD)
Medications Tried for Above Condition(s)
*
PCP Phone
Side Effects of medications?
Prior Diagnostic Tests and Treatments
*
Imaging: X-Rays, MRI, CAT scan, etc
Diagnosed by Primary Care Physician, Nurse Practitioner, Physicians Assistant, or other health professional
Surgery
Physical Therapy
Chiropractic care
Acupuncture
Massage
Counselling / Mental health care or evaluation
Dentist / Facial Pain specialist
Injections: Nerve blocks, painkillers, steroids, etc
No prior diagnosis, tests, or treatments
Allergies to Drugs or Foods?
List Major Health Issues. Include when it began and how it began, if known. Example: Back Pain, 3 years, Occupational - Flooring installer
*
Current Medications
*
Upload Health Records and/or Medication List - Required for Under age 18
Informed Consent
*
Yes
No
By clicking Yes, I attest that I am a patient at least 18 years old, or am the parent or guardian for the patient. I understand I am consulting with a physician or advanced practitioner for an evaluation and opinion as to whether I might benefit from the medical use of cannabis. In performing this evaluation, a bona fide physician-patient relationship is established to fulfill the health practitioner's role as defined by the constitution of the State of Colorado. I understand that if the physician or practitioner recommends cannabis, the decision to use medical cannabis is at my sole discretion. If and how I use cannabis is up to me. I understand cannabis is a drug and may cause side-effects such as drowsiness, dizziness, decreased reaction time, and euphoria. I will avoid hazardous activities, such as driving, or operating heavy equipment, if I have any of these side-effects when using cannabis. I understand that, as with any drug, there is a risk of dependence or addiction. I will notify my physician if I become pregnant.
Signature
*
By signing or typing my name above, I certify the information entered is true and correct to the best of my knowledge. I agree to the Privacy Policy on the Patient Forms page of this website. I understand I am financially responsible for any balance due. I authorize the use/release of my health information as needed by Healthy Choices Unlimited to provide me with care and to assist with my Colorado Medical Marijuana Registry application.
Is somone else paying for your visit today?
*
Yes
No
Payers Name
*
Date Signed
*
Upload Your ID
File types- jpg,pdf,png,gif. Colorado ID preferred. Out of state ID will cause delays
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