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Patient Information

Name *

First

Middle

Last

Date of birth *MM123456789101112/DD12345678910111213141516171819202122232425262728293031/YYYY202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920

Email *

Weight *

Height *

Gender *MaleFemale

Phone *

We will contact you soon to confirm your appointment.

Address *

Address Line 1

Address Line 2

City

AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingState

Zip Code

Make sure information provided here is correct.

How did you hear about us? *

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 California, and not by a lawsuit or resort to court process except as California 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.

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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? *

Initials *

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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). *

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. *

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. *

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. *

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. *

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 California law. The physician, physician assistant, nurse practitioner or mid-level practitioner at MMJ Doctors, will perform as consultants and will not assume the role of 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 the 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 are 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 receive 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

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.

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