Patient Intake Form.  Please fill out the form to start the process for a New, Renewal or Transfer Medical Marijuana Card for PCC Wellness Center of Florida:  239-268-3636, info@PCCFlorida.com
Please complete all fields, and as much information regarding your condition if not listed in advance so we can create your patient file. If you have any questions regarding any or our forms or opt to print this form or receive it by email please contact PCC so we may assist you.
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First Name ONLY as it appears on Drivers License *
Last Name as it appears on Drivers License *
Date of Birth *
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Social Security Number, REQUIRED FOR STATE *
Drivers License Number - REQUIRED FOR STATE *
Cell Phone Number *
Email Address *
FLORIDA Street Address *
FLORIDA City, State, Zip and County *
What is your Florida residency status *
If Foreign National, Passport Number
What is your Gender and Weight? *
Are you a Veterans?  If yes, Thank You for your Service *
Have you been diagnosed with any of the required conditions stated below or is your condition(s) or symptoms of the Similar or LikeKind (SKC), if so please answer following question. *
What is your diagnosis or conditions if not listed above. Please list your symptoms, ailments, pains, disorders, or speak with us to discuss them to help determine your condition for SKC. *
Please list your medications including OTC
Do you drink Alcohol more than 2 days per week? *
Do you use illegal drugs *
Do you smoke?  Cigarettes, Cigars, Other *
Signature, please print your full LEGAL Name *
Do you already have an appointment? *
What is this visit for? a New, Renewal, Or Transfer *
If you don't have an appointment, what day is for to schedule an appointment with the Doctor?  For future appointments what day and time is best?
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Are you a CareTaker?  Do you need a medical card to care for you LO?
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How did you hear about us? *
Would you please recommend us on Google, Maps, Facebook, Yelp, Alienable, LinkedIn, the dispensaries websites, etc?
Are you interested a DNA test to help you with the type Cannabis and Oil required specifically for you?
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Are you currently using or have you tried Hemp or CBD? Are you interested in information on either?
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Do you know someone who could benefit from Medical Marijuana or Hemp (CBD)?
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Do you or someone you know have interest in the benefits of Essential Oils, doTERRA?
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Would you be interested in Whole Foods Fruits, Vegetables, Berries, Omegas? MarZiaRiVera.JuicePlus.com look it up
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