Vibrant Health Clinic Intake Paperwork
Complete each section and submit 24 hours prior to your exam
Name *
Mailing Address, Street/City/Zip Code *
Phone Number (Cell) *
Phone Number (Home)
Social Security Number - This is only used for your Physician Certification
Military Veteran?
Clear selection
Email Address *
How did you hear about us? If a friend, be sure to add their name so they can benefit from our friend referral program. *
Your primary physician, chiropractor or naturopath?
1. You understand that Vibrant Health Clinic is a consulting clinic and is not authorized to sign a Physicians Certification for the State of Colorado. 2. You understand that only a licensed MD or DO is authorized to sign the Physicians Certification. 3. You understand that Vibrant Health Clinic does not offer a guarantee of service, recommendation, or certification of any kind. All sales are final and no refunds are issued. 4. You understand that Vibrant Health Clinic and any Physician associated with their treatment plan recommend a follow-up appointment to see how your medication is working within 6 months of your initial visit. Please print name and date below to acknowledge you understand and agree with above: *
I am consulting with the doctors at Vibrant Health Clinic in order to obtain a Medical Marijuana Registry Identification card to use for medication needs as outlined by Colorado law. *
Information that I share with the doctors in order to obtain a Medical Marijuana Registry Identification card is truthful, non-fraudulent, accurate and correct. *
I understand that my medical consultation is protected by standard HIPPA and medical confidentiality laws. *
I understand that use, possession, distribution and manufacture of marijuana are federal crimes in Colorado and a Medical Marijuana Registry Identification card does not protect me from federal criminal prosecution. *
I have read the Medical Marijuana Registry Patient Information sheet and will ask the doctor any questions I have about it during my appointment. *
Medical History
Please be as detailed as possible
Your current age *
Please check any of the following medical conditions you are currently experiencing: *
Required
If you checked Severe Pain, please describe the cause of the pain:
Please give details of the medical condition(s) checked above. How long have you had this? *
What is the cause (if known)?
What medications are you currently taking? Include dosage.
What herbal or vitamin supplements are you taking?
Do you currently use cannabis? *
If yes, what forms? Check all that apply:
Please list any chronic illness (diabetes, heart disease, asthma, etc.) and how long you have had it:
Please list any surgeries (type and year):
Please list any significant accidents or injuries:
Please note any treatment for psychiatric illness including addiction (type and year):
Do you smoke/use tobacco? *
If yes, give details of types and how much tobacco:
What is your average weekly alcohol intake and what kinds?
Please describe your work situation: *
Please describe your home situation: *
How well do you sleep? *
How well do you eat? *
How often do you exercise and what types *
Height *
Weight *
Ideal Weight *
How do you rate your general health? *
Women, are you pregnant?
Clear selection
Anything else you'd like the doctor to know?
Submit
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy