PATIENT PRE-APPOINTMENT FORM. Honolulu Wellness Center ~ Cannabis Care Clinic
Hawaii's Medical Marijuana ~ Cannabis 329 Registration Card
for more information.
Three (3) easy steps:.
Step 1: Fill in this form. And we will reply by call, text, and/or email to set an appointment and answer any questions.
Step 2: Come to your appointment, (We process all the state forms for you.) and
Step 3: Receive your 329 Medical Cannabis Ecard in your email a few business days after your appointment.
Date of Birth
Cell Phone [format: (808) 123-4567]
Which is/are your primary Eligible Debilitating Medical Condition(s)?
Seizures, including but not limited to seizures caused by epilepsy
Severe and persistent muscle spasms, including but not limited to those spasms caused by multiple sclerosis or Crohn's disease
Positive status for human immunodeficiency virus (HIV) or Acquired immune deficiency syndrome (AIDS)
Post-traumatic stress disorder (Must have medical records from a licensed mental health professional.)
Amyotrophic Lateral Sclerosis
I understand that I must bring related medical records to my appointment?
Have you had a medical cannabis card in the past?
Referral Source? How did you hear about us? Or write note here:
Medical Marijuana Card Processing with Aloha.
Form Click Agreement:
Ohana Kamaaina Special includes medical records analysis, face-to-face appointment, one-on-one time with our in-house Certified Medical Cannabis Consultant, file creation, application processing, two additional tele-med appointments if needed, and education. $188 Ohana Kamaaina Special ~ Full-Service First-Card Package, (Discounted $200.00 OFF from our regular $388.00 full-Package-Price) You will also be required to pay a $38.50 State Fee. [Additional $50.00 discount for Renewals: $138 Renewal Ohana Kamaaina Special if you have had a Medical Cannabis Card in the Past. Expired card or proof of former card must be present at appointment to enjoy this discounted price.]
This form is secure, private, and HIPAA Compliant.
HONOLULU WELLNESS CENTER Patient pre-appointment form click contract.
By Clicking the “Submit” CLICK AGREEMENT acknowledges that you agree to the following:
I attest that I will not engage in the diversion of cannabis. I understand that fraudulent distribution or resale of cannabis is a felony.
I understand that when under the influence of cannabis driving is prohibited and machinery should not be operated.
I understand all medical cannabis (all cannabis), should be kept away from children.
I acknowledge consumption of marijuana or marijuana manufactured products on the Honolulu Wellness Center, Plaza or anywhere on premises of the Honolulu Wellness Center is prohibited.
I understand there may be health risks associated with using cannabis.
I understand I may not distribute marijuana to any other individual.
I agree not to bring any weapons or anything that can be used as a weapon into Honolulu Wellness Center facilities.
I understand that I must have a valid government-issued identification (Driver’s License, State ID, or Passport.) during every visit to the Honolulu Wellness Center.
I understand that payment is non-refundable.
I agree at all times to abide by Hawaii law in regard to my use of medical cannabis and hereby release and waive all claims against Honolulu Wellness Center, Infinity Life Center, Paul Klink CMCC, Michael Pasquale DO, our staff, our vendors, our family, and associates from any and all liability related to my use of medical cannabis.
I certify that I the above is true and correct and agree to hold harmless and release Honolulu Wellness Center ~ Cannabis Card Clinic, and its officers, managers, agents, and employees of any liability related to the use of medical cannabis purchased at the Honolulu Wellness Center, during house calls for patients who can’t come into the office, or services offered by Honolulu Wellness Center.
I will always be honest and accurate in all my dealings with the Honolulu Wellness Center and it's staff.
I will not break any laws in any regards.
I understand that all sales are final, I can not request a refund, and no returns can be processed.
I consent that Honolulu Wellness Center staff may create, enter, and edit private applications to the State of Hawaii Department of Health 329 Registration Office on my behalf with information provided by me and release said staff to communicate on my behalf to same.
Agreed and Electronically Signed by Clicking Submit Button. Mahalo!
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