Integr8 Health Education Intake
Welcome, and thank you for taking a couple minutes to complete our intake and consent forms. We look forward to the opportunity to serve you. **Please do not use use your auto-fill function, it creates a problem for some users that prevents advancing and completing the form**

Please complete this form only if you are outside the state of Maine and have scheduled an education consult.
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Email *
First name *
Last name *
Date of Birth *
Address *
What is your gender *
Primary phone *
Secondary phone
Please describe your goal(s) for this educational consultation: *
Please list any specific questions you have for your medical cannabis educator: *
Please list all of your current medications, supplements, and herbs (with dosages): *
Please list any allergies (medications, food or environmental, & your reactions): *
Are you established with a local medical provider who oversees your use of cannabis? *
We like to send a copy of our notes to relevant members of your healthcare team. Please provide the names, locations, and specialties of providers you’d like to receive this information (include fax number if you have it): *
Cannabis History
Are you currently using cannabis? (If no, please skip to next section). *
Please describe your current cannabis dosage and delivery method (for example, 2 puffs of THC dominant smoke twice daily from a pipe, 40mg CBD oil in the AM and 10mg THC oil before bed, vaporized cannabis flower spread throughout the day averaging 4 grams per week, over the counter CBD oil 10 drops three times daily, etc.). Please be as specific as possible. *
What products are you using? Please include label information (feel free to send a link to a product website, photo of the product label, etc.): *
How does cannabis help you? *
In your experience with cannabis, what has worked well, and what hasn’t worked well? *
Have you had any negative effects from cannabis? *
Medical History (optional):
Our consultants are willing to review pertinent medical records prior to your consultation, but this is not required. Please feel free to provide any information about your current medical situation and medical history.
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