Patient Registration

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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.
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.
File types- jpg,pdf,png,gif. Colorado ID preferred. Out of state ID will cause delays