MMJ-DOCS INTAKE FORM
The following information MUST be completed to proceed with an appointment.
Sign in to Google to save your progress. Learn more
Email *
NAME (FIRST/LAST): *
DATE OF BIRTH (mm/dd/yyyy): *
GENDER: *
PHONE (###)###-####: *
FULL ADDRESS: (STREET, CITY, ZIP) *
STATE DRIVERS LICENSE OR ID #: *
I AM APPLYING FOR A MMJ CARD IN: *
Required
APPOINTMENT TYPE: *
CONDITION(S): *
Required
How long have you been dealing with your condition and what causes it?  *
What RX prescriptions are you taking for condition?
*
How has Medical Marijuana helped your condition if you are a patient in the program?  *
Are you seeing a therapist or counselor?  *
What method(s) of treatment have you utilized? *
Required
IF RECERTIFICATION, WHEN DOES YOUR CURRENT MMJ CARD EXPIRE?
IF RECERTIFICATION, WHAT FORM(S) OF MEDICATION DID YOU FIND BEST FOR TREATMENT OF YOUR CONDITION?
Q1: Does your medical condition(s) cause you a feeling of nervousness, anxiousness, or on edge? *
Q2: Do you feel that you are unable to stop or control worrying about your medical condition(s)? *
Q3: Does your medical condition(s) cause you to worry too much about different things? *
Q4. Does your medical condition(s) cause you not to be able to relax? *
Q5: Does your medical condition(s) cause you being so restless that it is hard to sit still? *
Q6. Does your medical condition(s) cause you to become easily annoyed or irritable? *
Q7. Does your medical condition(s) make you feel afraid as if something awful might happen?
*
Q8. Have you had nightmares about your medical condition(s) or thought about the condition(s) when you did not want to?
*
Q9. Have you tried hard not to think about the event(s) or went out of your way to avoid situations that reminded you of your medical condition(s)?
*
Q10. Have you been consistently on guard, watchful, or easily startled when dealing with your medical condition(s)?
*
Q11. Has your medical condition(s) caused you to feel numb or detached from people, activities, or your surroundings?
*
Q12. Have you felt guilty or unable to stop blaming yourself or others for your condition(s) or any problems the condition(s) may have caused?
*
Please provide additional information pertaining to your condition(s) that you would like the physician to be aware of:
CONSENT TO TREATMENT/APPOINTMENT:
PATIENT RIGHTS ~
• Each patient will be treated with respect and dignity. Our staff will provide a courteous and professional atmosphere without discriminations to race, religion, ethnicity, disability, or sexual orientation.
• Each patient will participate in the decision-making process regarding your healthcare treatment and verification process.
• Each patient will be provided with a safe environment. 
• Each patient will have appropriate suitable privacy regarding communication and medical records.
• Each patient’s medical information is protected by HIPAA.
• Each patient will be informed of the name and credentials of the person interacting with them. 
• Each patient may refuse participation in the verification process through mmj-docs LLC at any point of their encounter. 
• Each patient has the right to voice a grievance and/or suggestion without the fear of restraint or discrimination. 
• Prior to obtaining and releasing confidential medical records, the patient must consent and release information as indicated.

PATIENT RESPONSIBILITIES ~
• Patient must provide accurate and complete medical information regarding his/her health status, prior illnesses, medications, and other matters that are pertinent for the verification process. 
• Patient should voice their concerns to staff regarding eligibility in the verification process for the use of medicinal marijuana. 
• Patient must comply with the regulations established through MMJ-Docs LLC and the Commonwealth of Pennsylvania.
• Staff and Patients are mandated to report abuse, neglect, or exploitations to the Pennsylvania Department of Children and Family Grievances. 
• Patients are to provide and authorize the release of necessary records from appropriate sources.
• Patient needs to act in respectful and considerate manner to the staff of MMJ-DOCS LLC
• Patient needs to ask questions and seek clarifications in areas of concern. 
• Patient must fulfill financial obligations at the time services are rendered through MMJ-DOCS LLC . 
• Credit Card transaction will display as MMJ-DOCS LLC  on banking statement. Should a dispute resulting in take back of payment for services rendered, certification will be terminated within 48-hours of notice provided by MMJ-DOCS LLC of said issue.
• Patient understand MMJ-DOCS may make any changes to the patient's treatment plan during their validation period, and MMJ-DOCS reserves all rights to terminate patient’s treatment. MMJ-DOCS is not responsible for any actions or liabilities caused from terminating patient treatment. 

LIABILITY WAIVER ~
• I hereby acknowledge that I have been instructed about the risks associated with utilizing medical marijuana. 
• I understand that the physician is providing me with a certificate to medicate with medical marijuana per the guidelines of the Pennsylvania Department of Health's Medical Marijuana Program (PA DOH MMP), and understand that the PA DOH MMP is the governing agency for the medical program in which I will adhere to their guidelines for participation. (PA DOH MMP Website - https://www.pa.gov/guides/pennsylvania-medical-marijuana-program/) - PA RESIDENT
• I will consult with a legal professional regarding questions or concerns regarding firearms and medical marijuana use. 
• I understand that operating a vehicle, machinery, or other motorized vehicle can be hazardous to myself and others while using medical marijuana. I understand that if I am operating a vehicle while utilizing medical marijuana, I may be found under the influence according to state and/or federal law. 
• I understand that utilizing medical marijuana may provide possible side effects, as with any other medication, and hereby hold harmless MMJ-DOCS for any personal actions I pursue while utilizing medical marijuana.
• I understand that although I may possess medical marijuana legally with a medical card, I must still adhere to my employer’s company policy regarding medical marijuana and controlled substances. Each company's policy is different, and I may be subject to disciplinary actions or termination if using medical marijuana is against said policy. I.e. Federal employees, truck drivers, etc. MMJ-DOCS does not provide any documentation specific to medical marijuana use and employment.
• I understand medical marijuana is legal to possess and use medically in Pennsylvania, and that crossing state lines with medical marijuana is federally illegal. Medical Marijuana is still considered illegal on federal property within Pennsylvania. I.e. federal buildings and federal parks or forest. 


I hereby certify that I have read and understand all sections within the Consent to Treatment.
*
Required
A copy of your responses will be emailed to the address you provided.
Submit
Clear form
Never submit passwords through Google Forms.
reCAPTCHA
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy