Page 1 Page 2 First Name * Last Name * Middle Social Security Number * Status SingleMarriedDivorcedOther 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 Summit County 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
