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FLORIDA MEDICAL MARIJUANA DOCTOR ONLINE APPLICATION
COMPLETE THIS FORM
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Step
1
of 3
Patient Information
Name
*
First
Middle
Last
Date of birth
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Email
*
Weight
*
Height
*
Gender
*
Male
Female
Phone
*
We will contact you soon to confirm your appointment.
Social Security Number
*
Required to register with DOH
Address
*
Address Line 1
Address Line 2
City
Alabama
Alaska
Arizona
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California
Colorado
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Delaware
District of Columbia
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Idaho
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South Carolina
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Tennessee
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State
Zip Code
Make sure information provided here is correct.
How did you hear about us?
*
Google, Yelp, Bing, Friend, Coupon, Referral, etc.
PHYSICIAN-PATIENT ARBITRATION AGREEMENT
AGREEMENT TO ARBITRATE: It is understood that any dispute as to medical malpractice, that is as to whether any medical service rendered under this contract were unnecessary or unauthorized or were improperly, negligently, or incompetently rendered, will be determined by the submission to arbitration as provided by Florida, and not by a lawsuit or resort to court process except as Florida law provides for judicial review of arbitration proceedings. Both parties to this contract, by entering into it, are giving up their constitutional right to have any dispute decided in a court of law before a jury, and instead, are accepting the use of arbitration.
Signature
*
Clear Signature
I hereby acknowledge and agree that I will be responsible to the doctor for payment of entire bill.
Next
Controlled Substance Informed Consent Form
The following agreement relates with my use of controlled substance prescribed by MMJ Doctors physician(s). I will be provided controlled substances while actively participating in my treatment plan ONLY if I adhere to the following: 1. I will use the substances only within the parameters by my treating physician 2. I will not receive replacement medications for “lost” or “stolen” medications without presenting a valid police report. 3. I agree to submit to URINE AND BLOOD TESTINGS at any time. 4. I will not expect to receive additional medications prior to the time of my next scheduled refill, regardless if my new prescription runs out for “stretching out” my medications if my new prescription is dated for a weekend, holiday or any other date when I cannot refill my prescription. I understand that prescriptions will not be rewritten for a new day under any circumstances. 5. I agree to submit URINE PREGNANCY TEST at any time if required by physician and I will NOTIFY MMJ DOCTORS CLINIC IMMEDIATELY AFTER I AM AWARE THAT I AM PREGNANT. 6. By law, a maximum of thirty (30) days’ supply of medicine will be prescribed at any one time. 7. I will accept generic brands of my prescription medication. 8. If it appears to the physician that there are no demonstrable benefits to my daily function of quality of life from the controlled substance, I will gradually taper my medications as prescribed by the physician. I will not hold any member of MMJ Doctors liable for problems caused by discontinuation of controlled substance(s). 9. I agree to medication counts as needed , within a 24-hour notice. 10. I give my permission to MMJ Doctors staff to contact my previous pharmacy and previous prescribing physician(s) for pertinent information if required by physician. 11. I give my permission to MMJ Doctors staff to check PMP for my controlled substance prescription history. 12. I agree not to sell, share or give any of medications to another individual; I agree not to obtain controlled medications(substance) for the same purpose from another physician or other sources without informing my MMJ Doctors physician(s).
Signature
*
Clear Signature
HEALTH QUESTIONNAIRE
Check if you have any of the following condition(s): (Please leave boxes blank if they do not apply to You)
Conditions / Symptoms
*
ADD / ADHD
Anxiety
Depression
Phobias
Ulcer
Social phobia
Nervousness
Cerebral palsy
Post-Traumatic Stress Disorder
Bipolar
Positive Status HIV/AIDS
Insomnia
Chronic Pain
ALS
Parkinson's disease
Multiple Sclerosis
Spinal cord damage with spasticity
Epilepsy
Inflammatory Bowel Disease (IBD)
Neuropathies
Huntington's decease
Other health complications not listed:
Allergies
*
LIST ALL MEDICATIONS YOU ARE CURRENTLY TAKING OR HAVE PREVIOUSLY TAKEN
*
WHO IS THE MOST RECENT PHYSICIAN YOU HAVE SEEN?
*
DOCUMENTS UPLOAD
Please provide us with all documents required by DOH
Patients ID or Driver's License
Medical Records, Records of Treatment, etc.
Initials
*
Next
Disclosures and Conditions
Please read carefully and initial each paragraph.
Based on my belief and general information that I have obtained from different sources, which includes researching scientific literature about the established benefits and risks of using medicine(s) to treat my medical problems, I request the doctor to EVALUATE me for a possible prescription and responsible usage of medicine(s).
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I agree to provide the physician with any and all copies of my MEDICAL RECORDS, if they exist, that document my medical conditions, as requested by the physician.
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I agree to obtain medical FOLLOW-UP at my personal medical doctor’s office, or obtain a personal doctor if I have none now, and to return to this office for FOLLOW-UP, as recommended by the physician. I understand this is an obligation on my part for the continuity of care. Annual doctor visits are the minimum.
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I have been assured that medical records relating to my care will be kept private and confidential and that no information will be released or printed, which would disclose my personal identity, unless required by law.
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I do not have any active lawsuits or investigations against or involving this clinic, its physician(s), or its employees, nor am I a representative of any authorities who do.
*
Signature
Clear Signature
Furthermore, the undersigned, my heirs, assigns, or anyone acting on my behalf, hold the physician, the principals, agents and employees, free and harmless of any liability resulting from the use of medicines or services from this clinic. This clinic, its staff and representatives are addressing specific aspects of my medical care, and unless otherwise stated are in no way establishing themselves as primary care provider. Should an approval be made for my medicinal prescription or services provided, I understand that terms and return dates will be specified. I understand that it is my responsibility to see a physician to assess the possible continuance of prescribed medicine(s) or provided service(s) beyond the terms of approval. I understand that the benefits and risks associated with the use of medicine(s) or service(s) may not be fully understood and that the use of medicine(s) or service(s) may involve risks that have not been identified. I certify that I have carefully read all the DISCLOSURES and CONDITIONS above with full understanding and agreement. I certify that all information I have provided in this ‘form’ is true and correct. I certify that all information verbally transmitted to the doctor is true and correct. I am seeking medication(s) or service(s) for my own, personal, medical use. I am aware that if any of my document(s) are lost or stolen medical document(s) replacement fee(s) may apply.
WAIVER
I hereby release MMJ Doctors, all its employees from any liability whatsoever associated with or connected to consultation and/or use of cannabis. I acknowledge that I am legally responsible for and aware of the potential side effects associated with cannabis. I understand that no physician, physician assistant, nurse practitioner, mid-level practitioner, nurse, pharmacist, or administrative personnel can guarantee that cannabis will provide the results I seek. I am participating in this program by my own choice, and assume all responsibility for my use of cannabis. MMJ Doctors is a practice limited to evaluations of patients and ordering of medical cannabis products for those patients qualified under Florida law. The physician, physician assistant, nurse practitioner or mid-level practitioner at MMJ Doctors, will perform as consultants and will not assume the role as the attending physician for patients. No advice or treatment of any kind will be provided for any condition other than those indicated for medical cannabis products. No traditional medical prescriptions will be provided to patients. No exceptions. All patients should be under the care of a primary care physician. It is the responsibility of the patient to inform his/her physicians of cannabis product use. Cannabis products will NOT be provided by MMJ Doctors. Patients have the right to select the dispensary from which they will purchase the products. Patients will be evaluated in person by the physician, physician assistant, nurse practitioner or mid-level practitioner prior to ordering of any cannabis products. Not all patients evaluated will be determined to be appropriate for cannabis use. I fully understand that it is my responsibility to have an annual in person physical examination along with necessary follow-up consultations. Your registry ID card does not give you the legal right to use recreational marijuana. Your registry ID card and certification do allow you to purchase your cannabis recommendation from a state approved dispensary. You may test positive on a drug test for marijuana by using medical marijuana or low-thc cannabis purchased from a dispensary which may not be acceptable to your employer or other entities. Certification and use of medical marijuana is not to replace your traditional pharmaceutical therapy and/or treatment plan and you will still need to be managed by your primary care provider. Electronic Communications: By agreeing to this notice, you consent to receiving electronic communications. These electronic communications may include notices about applicable fees and charges, transactional information and other information concerning or related to services provided. These electronic communications are part of your relationship with MMJ Doctors . You agree that any notices, agreements, disclosures or other communications that we send you electronically will satisfy any legal communication requirements, including that such communications be in writing
Signature
Clear Signature
I have read or have had read to me the above explanation of the waiver. I acknowledge that I have received and had the opportunity to review the waiver on behalf of MMJ Doctors. Having been informed of this policy, I hereby give my informed consent.
Electronic Signature. Type in your full legal name:
*
I understand that by typing in my full legal name I am hereby signing this application electronically. I further understand and agree that my electronic signature is the legal equivalent of my manual/handwritten signature on this application. I warrant the truthfulness of the information provided in this application.
Appointment information
Preferred date and time of consultation?
*
Date
Time
We are open 7 days a week from 11 am to 7 pm. Walk-ins accepted. Appointment can take up to 30 min.
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