PATIENT PRE-APPOINTMENT FORM. Honolulu Wellness Center ~ Cannabis Care Clinic
Three (3) easy steps:
STEP 1: Please, fill in this form. And we will reply by call, text, and/or email usually within 72 hours, depending on the number of forms received, to set an appointment and answer any questions. Also, for quicker response, since we get a lot of pre-appointment forms: feel free to text (808) 798-3629 anytime or if you can't text, call us at 808-798-3629 (M-F 9a-5p) to set up your appointment AFTER you have submitted this form.
STEP 2: Please, come to your appointment prepared, on time, and bring your:
A.) UNEXPIRED ID: Only a Driver's License, State ID, or Passport. (any state or country)
B.) MEDICAL RECORDS from a medical professional or facility showing your selected diagnosis below.
C.) PAYMENT: First-time card is $226.50 all-inclusive (Itemized: $188 sale price plus $38.50 state fee) and the renewals are $176.50 all-inclusive (Itemized: $138 discounted sales price, plus $38.50 State Fee)
~ Payment preferably in cash with exact change, please. Or the less favorable option is debit or credit card which as you know, costs considerable fees from the financial institutions which, in turn, raise prices.
STEP 3: Receive your Medical Cannabis Ecard from the State of Hawaii, Department of Health, ASAP.
for more in-depth information.
"Patient Advocacy through Aloha and Education!" Ptr. Paul Klink, CMCC (Volunteer Patient-Advocate and CMCC = Certified Medical Cannabis Consultant) This is our Aloha Mission!
Date of Birth
Cell Phone (Please, format like this: 8087983629)
Do you plan on growing up to 10 plants?:
Do you plan on having a Caregiver? They will have to attend your appointment with you:
Which eligible debilitating medical condition are you bringing Medical Records for?
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
YES! I understand that I must bring related medical records from a licensed medical professional to my appointment for your diagnosis verification. If records need to be transmitted to our offices prior to your appointment please use email: All+Records@4HWC.com or FAX: 808-356-0720
Have you applied for a Hawaii Medical Cannabis Card with Honolulu Wellness Center before?
How did you hear about us? Or use this field to send us a note with your application:
Medical Marijuana Card Processing with Aloha.
Honolulu Wellness Center Patient Pre-appointment Form Click-Agreement.
Ohana Kamaaina Special includes medical records analysis, face-to-face appointments, 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 Honolulu Wellness Center Renewals: $138 Renewal Ohana Kamaaina Special if you have had a Medical Cannabis Card in the Past here in Hawaii. Expired card or proof of former card must be present at appointment to enjoy this discounted price.]
PROCESSING TIMES vary based on COVID Working Conditions, Triage status of pending applications to be processed by the state (Cancer Patients, ALS Patients, etc. get pushed to the front of the processing line. We can usually get a fairly good estimate at the time of approval in our offices and throughout the process. It's good to be a patient Patient.
Process: We do what you pay us to do the same day we see you if all information, documentation, and payment are cleared. (In office for first-time patients, TeleMed for previous 329 Patient appointment, creation of an account at the State of Hawaii eHawaii, Complete your 329 Application, Approve your 329 Application, work with the state to help them process your application, delivery of your finished Card as soon as it's available from the state.) the same day we see you, then we're all awaiting the processing from the state of Hawaii 329 office staff who are very compassionate, hard-working, and truly caring patient advocates like us. Their workload is unimaginable and it's good to keep this in mind with managing your expectations.
This form is secure, private, and Google HIPAA-Server Compliant.
CLICK AGREEMENT: By Clicking the “Submit” button below you acknowledge that you agree to the following Cannabis Card Processing agreement:
~ I attest that I will not engage in the diversion of cannabis. I understand that the fraudulent distribution or resale of cannabis is a felony. (Don't share your medicine with anyone. Your name on your card allows you access to cannabis...no one else.)
~ 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 an UN-Expired valid government-issued identification (ONLY: Driver’s License, State ID, OR Passport. NO other form of identification can be used to apply.) during every visit to the Honolulu Wellness Center.
~ I understand any payment to the State of Hawaii and Honolulu Wellness Center is non-refundable no matter the circumstances.
~ 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 application for 329 Card (State and HWC do not offer refunds.), the use of medical cannabis, or any other cause.
~ 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 its staff.
~ I will not break any laws in any regard.
~ I understand that all sales are final, I can not request a refund, and no returns can be processed regardless of circumstances.
~ RECORDS REQUESTS: I understand that we only provide records to the patient to distribute to whomever they choose. We won't charge for research, processing the request, nor for electronically transmitting to the patient via email. Records release only refer to an image of your State of Hawaii Department of Health 320 Registration Application and your 329 Card image. We do not accept nor store any information patient brings to their appointment. All materials are returned to the patient.
I consent that Honolulu Wellness Center staff may create, enter, and edit private State of Hawaii (SOH) eHawaii account(s) and SOH Department of Health (DOH) 329 medical cannabis card application(s) to the SOH DOH, & SOH DOH 329 Registration Office on my behalf with the information provided by me and release said staff to communicate on my behalf to same.
Agreed and Electronically Signed by Clicking Submit Button. Mahalo!
!!! We usually can't keep up with all the forms due to demand. Please... FOR IMMEDIATE ASSISTANCE, quicker appointment setting, answers to questions, or if you feel ready to set up an appointment PLEASE ideally TEXT or if you can't text CALL us Monday thru Friday between 9 am and 5 pm at 808-798-3629, after you've submitted this form....and we'll answer any questions and set up an appointment if you'd like.
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